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UNIVERSITY  O:  C/l.-ORNIA 
CALIFORNIA  COLLEGC  OF  MEDICINE 

LiervARY 

SEP    13    1973 


IRVINE.  CAUFORNIA  92664 


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DIAGNOSIS    OF    SMALLPOX 


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THE   DIAGNOSIS  OF 
SMALLPOX 


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BY 


T.    F.    RICKETTS 

M.D.,  B.Sc.  (Lond.),  M.R.C.P.,  D.P.H. 

Medical  Superintendent  of  the  Smallpox  Hospitals  and  of  the  River 
Ambulance  Service  of  the  Metropolitan  Asylums  Board 


ILLUSTRATED    FROM    PHOTOGRAPHS    BY 

J.  B.  BYLES 

M.B.,  B.C.  (Cantab.),  F.R.C.S.  Eng.,  D.P.H. 

Senior  Assistant  Medical  Officer  at  the  Smallpox  Hospitals  of  the 
Metropolitan  Asylums  Board 


WITH     12    COLOURED    PLATES,     1 10     BLACK-AND-WHITE 
PLATES,    AND    1 4    CHARTS 


NEW    YORK 
FUNK    AND    WAGNALLS    COMPANY 

1910 


^  10 


PREFACE 

It  is  ten  years  or  more  since  the  author  conceived 
the  notion  of  "\vi'iting  this  book.  He  was  deterred 
by  the  consideration  that  it  would  have  but  little 
value  unless  adequately  illustrated,  and  to  the 
execution  of  that  i)art  of  the  task  he  did  not  see 
the  way.  Some  years  later  the  project  was  revived 
at  the  suggestion  of  Mr.  E.  L.  Meinertzhagen, 
chairman  of  sub-committee  of  the  metropolitan 
smallpox-hospitals,  who  urged  the  author  to  under- 
take the  preparation  of  the  work  and  secured  the 
co-operation  of  the  Metropolitan  Asylums  Board. 
It  is  owing  to  the  facilities  extended  to  us  by  the 
Board  that  the  realisation  of  the  project  has  become 
possible. 

As  to  the  importance  of  the  subject  and  the 
need  for  its  exhaustive  treatment  there  will  probably 
not  be  two  opinions,  though  there  may  be  several 
opinions  about  the  value  of  this  result.  Perhaps 
the  most  noteworthy  difference  from  the  teaching 
of  previous  writers  on  the  subject  resides  in  the 
importance  attributed  to  the  distribution  of  the 
eruption :  a  diagnostic  criterion  which  has  been 
lifted  from  a  subordinate  to  a  leading  position. 
This    doctrine    may    sound    more    novel    elsewhere 

{MKELEI 


^L  nUr, 


vi  PREFACE 

than  in  London,  where  it  has  been  taught  by  the 
author  to  his  colleagues  and  pupils  for  the  last 
fifteen  years.  It  has  been  abundantly  justified  by 
the  experience  gained  in  the  diagnosis  of  many 
thousands  of  cases. 

In  spite  of  the  number  of  illustrations,  there 
are  still  some  gaps  which  remain  unfilled  or  are 
filled  imperfectly.  This  circumstance  is  due  to  the 
fact  that  while  the  work  has  been  in  preparation 
smallpox  has  not  attained  epidemic  proportions  in 
London,  and  certain  subjects  of  infrequent  occur- 
rence have  not  been  avd-ilable  for  record.  Thus 
it  would  have  been  an  advantage  to  present  some 
further  illustrations  of  hsemorrhagic  or  toxic  small- 
pox. 

In  compensation,  we  are  so  fortunate  as  to  have 
several  of  the  illustrations  in  colour.  These,  we 
think,  will  be  of  particular  value  in  conveying 
accurate  and  life-like  impressions  of  the  subjects 
treated.  It  may  be  of  interest  to  state  that,  with 
the  exception  of  the  frontispiece,  these  colour-plates 
are  produced  from  triple  negatives  obtained  by  the 
Sanger  -  Shepherd  process  of  colour  -  photography. 
We  believe  this  to  be  the  first  medical  work  which 
has  been  freely  illustrated  by  means  of  colour- 
photographs  taken  from  life.  Very  obvious  is  the 
advantage  in  point  of  fidelity  over  the  coloured 
illustrations  of  medical  subjects  ordinarily  obtained 
by  means  of  water-colour  drawings. 

Among  the  half  -  tone  plates  are  a  number  of 
stereoscopic    subjects.        Readers     are     advised     to 


PREFACE  vii 

examine  these  through  one  of  the  cheap  pocket - 
stereoscopes  which  may  now  be  obtained  at  many 
opticians'.  In  spite  of  the  fact  that  the  cross- 
hatching  of  the  process  -  screen  becomes  unduly 
obvious  when  magnified  by  the  stereoscope,  con- 
siderable assistance  will  be  derived  from  its  use. 
But  these  stereoscopic  prints  are,  of  coui'se,  by  no 
means  valueless  when  viewed  by  the  naked  eye. 

With  one  exception  (Plate  xxxiii.,  Fig.  2),  all 
the  prints  are  from  photographs  taken  of  patients 
with  smallpox  or  of  patients  whose  illness  had 
been  mistaken  for  smallpox.  For  the  photographic 
original  of  Plate  xxxiii.,  Fig.  2,  we  are  indebted  to 
Dr.  A.  F.  Cameron,  of  the  South-Eastern  Metro- 
politan Fever  Hospital. 

We  take  this  oppoiiiunity  of  expressing  our 
great  indebtedness  to  Dr.  Frederick  Thomson, 
medical  superintendent  of  the  North-Eastern  Metro- 
politan Fever  Hospital,  and  at  one  time  acting 
medical  officer  of  the  Metropolitan  River-Ambulance 
Service  for  smallpox.  To  his  co-operation  we  owe 
opportunities  of  securing  records  of  several  of  the 
cases  of  mistaken  diagnosis  illustrated  in  the  plates 
and  of  some  cases  of  smallpox  which,  without  his 
assistance,  would  have  come  under  our  notice  too 
late  to  be  of  value. 

T.  F.  R. 
J.  B.   B. 

October,  1908. 


CONTENTS 

CHAPTER  PAOB 

I.  Introductory          .......  1 

II.  Distribution 6 

III.  Distribution  {continued)         .         .         .         .         .  14 

IV.  Diagnosis  by  Distribution 21 

V.  The  Lesion 26 

VI.  The  Eruption  and  the  Eruptive  Fever       .         .  33 

VII.  Modified  Smallpox 43 

VIII.  Secondary  Characteristics  op  the  Eruption       .  51 

IX.  The  Toxemic  Fever 58 

X.  T0X.EMIC  Rashes     . 66 

XI.    HiEMORRHAGIC   SYMPTOMS 73 

XII.    H.EMORRHAGIC   OR   ToXIC   SMALLPOX             .            .            .  85 

XIII.  H.EMORRHAGIC  OR  Toxic  Smallpox  (concluded)       .  95 

XIV.  Erythemata  :  Simple  and  Symptomatic         .         .  104 
XV.  Chickenpox 117 

XVI.  Syphilis— Vaccinia 125 

XVII.  Dermatitis — Pustular  Dermatoses        .        .        .132 

XVIII.  Vaccination  as  a  Factor  in  Diagnosis        .        .  141 

INDEX 149 


2141 


LIST    OF     PLATES 


Frontispiece  {in  colour) : 

Histological  section  of  a  variolous  lesion. 


PLATE 
I. 
II. 
III. 

IV. 


Irritation-patches     ....... 

Irritation-patches     ..... 

Disti-ibution  influenced  by  attire       .... 

Fig.  1,  Garter  mark ;  Fig.  2,  Friction  of  the  trouser- 
end  .... 

V.  Fig.  1,  Friction  of  the  collar ;  Fig.  2,  The  eflect  of 
inflammation     . 
VI.  Protection  from  irritation 
VII.  Tendinous  ridges 
VIII.  Distribution  on  the  foot  . 
IX.  Distribution  on  the  foot  . 
X.  Distribution  on  the  foot  and  on  the  hand 
XI.  Distribution  on  the  hand  and  wrist . 
XII.  Distribution  on  the  upper  part  of  the  body 

XIII.  Distribution  on  the  back  ..... 

XIV.  Distribution  on  the  back  ..... 
XV.   Distribution  in  the  case  of  a  child    . 

XVI.  Fig.   1,   Distribution  on    the    chest    and    abdomen 
Fig.  2,  The  popliteal  space 
XVII.   Distribution  on  the  arm  ..... 
XVIII.   Distribution  on  the  upper  part  of  the  body 
XIX.  Distribution  on  the  upper  part  of  the  body 
XX.   Distribution  on  the  legs  ..... 
XXI.  Distribution  on  the  face  ..... 
XXII.  Fig.    1,   Distribution  on    the  face;    Fig.  2,  Distri 
bution  on  the  chest  and  abdomen 

XXIII.  Distribution  on  the  neck 

XXIV.  Distribution  in  the  case  of  a  child    . 
XXV.  Distribution  in  the  case  of  a  woman 

XXVI.   Distribution  on  the  arm  . 
XXVII.  Pustular  dermatitis 


PAOE 

12 


20 


24 


xu 


LIST    OF    PLATES 


PUATB  rAC 

XXVIII.  Pustular  dermatitis     ..... 

XXIX.  Chickenpox         ...... 

XXX.  Erytheraa  multiforme  .... 

XXXI.  Erythema  papulatum  ..... 

XXXII.  Erythema  multiforme  .         .         . 

XXXIII.  Fig.  1,  Erythema  multiforme ;  Fig.  2,  Measles 

XXXIV.  Acute  pemphigus         ..... 
XXXV.  Fig.   1,  Urticarial  lesions  on  the  hand ;  Fig.   2 

Meagre  variolous  eruption     ... 
XXXVI,  Chickenpox         ...... 

XXXVII.  Evolution  of  the  lesions       .... 

XXXVIII.  Evolution  of  the  lesions      .... 

XXXIX  (Stereoscopic.)     Evolution  of  the  lesions 
XL.  (In  colour.)     Early  variolous  vesicles . 
XLI.  (In  colour.)     Advanced  variolous  vesicles    . 
XLII.  (In  colour.)     Early  variolous  pustules 
XLIIL   (In  colour.)     Advanced  variolous  pustules  . 
XLIV.  (Stereoscopic.)     Variolous  pustules 
XLV.  (Stereoscopic.)     Fig.   1,  Variolous  crusts;  Fig.  2 
Spurious  umbilication    .... 

XLVL  Umbilication      ...... 

XLV II.  Method  of  outcrop 

XLVIII.  Severe  confluent  smallpox — papular  stage    . 
XL IX.  Severe  confluent  smallpox — pustular  stage  . 

L.  (Stereoscopic.)       Confluent     smallpox  —  papular 
stage    . 
LI.  (Stereoscopic.) 

stage     . 

LII.  (Stereoscopic.)      Confluent    smallpox  —  pustular 
stage  and  stage  of  incrustation 
LIII.  (Stereoscopic.)     Confluent  smallpox 
LIV.  (Stereoscopic.)     Confluent  smallpox 
LV.  (Stereoscopic.)    Fig.  1,  Mild  confluent  smallpox 
Fig.  2,  Discrete  smallpox       ... 
LVI.  Fig.  1,  Confluent  papular  eruption  ;   Fig.  2,  Con 
fluent  eruption  of  virulent  type 
LVII.  Fig.  1,  Discrete  smallpox  modified  ;  Fig,  2,  Con 
fluent  smallpox  modified — papular  stage 
LVIII.  Confluent  smallpox  modified — vesicular  stage 
LIX.  Confluent  smallpox  modified — pustular  stage 
LX.  (Stereoscopic.)     Incompletely  modified  eruption 


Confluent    smallpox  —  vesicular 


PAGE 

24 


32 


40 


LIST    OF    PLATES 


Xlll 


PLATE  FA( 

LXL  {In  colour.)     Modified  vesicular  eruption    . 

LXII.  Lesions  of  modified  smallpox 

LXIII.  [Stereoscopic.)     Lesions  of  modified  smallpox 

LXIV.  (Stereoscopic.)     Lesions  of  modified  smallpox 

LXV.  Granulomata      ...... 

LXVI.  A  pustular  sj'philide  .... 

LXVII.  Variolous  blebs  ..... 

LXVIIL  Fig.  1,  Lesions  of  inoculation ;  Fig.   2,  Crusts 
in  the  soles  ..... 

LXIX.   {Siereoscojnc.)     Cicatrices  on  the  face 
LXX.   Disfigurement    caused    by    confluent    modified 
smallpox      ...... 

LXXI.  Fig.  1,  Desquamation ;     Fig.   2,  Cicatrices  and 
pigmentation       ..... 

LXXII.  {In  colour.)   •  Obsolescent  variolous  eruption 
LXXIII.  Fig.  1,  Pigmentation  ;  Fig.  2,  Septic  rash 
LXX IV.  {Stereoscopic.)     Septic  rash 
LXXV.  Toxsemic  rash,  purpuric    .... 

LXXVI.  Toxsemic  rash,  purpuric   .... 

LXXVII.  Tox£emic  rose-rash,  scarlatiniform     . 

LX XVIII.  Toxemic  rose-rash,  morbilliform,  on  forearm 

LXXIX.  (Stereoscopic.)    Fig.  1,  Toxsemic  rash,  purpuric; 

Fig.    2,    Toxsemic    rose-rash,    morbilliform, 

on  forearm  ...... 

{In  colour.)    Toxsemic  rose-rash,  morbilliform, 
on  buttocks  and  thighs        .         .  .  . 

{Stereoscojnc.)  Toxtemic  rose-rash,  morbilliform, 
generalised ....... 

Toxemic  rose-rash,  morbilliform,  generalised 
Post-toxaemic  haemorrhage         .  . 

Fig.   1,  Post-toxaemic  haemorrhage ;  Fig.  2,  cir- 
cumscribed   cutaneous    hajmorrhagic    extra- 
vasations    ....... 

Subvesicular  and  perivesicular  haemorrhage 
Toxic  smallpox  .'.... 

{Stereoscopic.)     Toxic  smallpox 
{Stereoscopic.)     Toxic  smallpox 
{Stereoscopic.)       Vesicular    eruption   of    toxic 
smallpox     ....... 

Blood-stained  vesicular  eruption  of  toxic  small- 
pox    ........ 


LXXX 

LXXXI 

LXXXIL 
LXXXIIL 
LXXXIV. 


LXXXV. 

LXXXVI. 

LXXXVII. 

LXXXVIII. 

LXXXIX. 

XC. 


PAGB 

40 


56 


72 


84 


92 


100 


XIV 


LIST    OF    PLATES 


PLATE  FACISO    PAGE 

XCI.  {In    colour.)      Blood-stained   papular  eruption   of 

toxic  smallpox  .  ■       .         .         .         .         ,         •     100 

XCIL  Measles 116 

XCIIL  {In  colour.)     Measles     ..... 

XCI V.  Papular  variolous  eruption  mistaken  for  measles 
XCV.  Head  and  shoulders  of  a  woman  with  measles 
XCVI.  Erythema  nummulare    ..... 

XCVII.  Fig.    1,  Erythema   rheumaticum  ;    Fig.  2,  Vesicu 
lar    eruption    in  *a    case    of    erythema    multi- 
forme      ....... 

XCVnL  Fig.  1,   Erythema  multiforme  ;    Fig.  2,  Erythema 
papulatum         ...... 

XCIX.  {In  colour.)     Lesions  of  erythema  papulatum 
C.  Erythema  papulatum     ..... 

CL  Fig.    1,    Erythema    multiforme;     Fig.    2,    Acute 
urticaria  ....... 

CII.  Acute  urticaria      ...... 

cm.  {In  colour.)     Lesions  of  acute  urticaria  . 
CIV.  Acute  febrile  erythema  ..... 

CV.  Acute  febrile  erythema  ..... 

CVI.  Acute  febrile  erythema  .         . 
CVII.  Acute  febrile  erythema  ..... 

CVIII.  Fig.  1,  Lesions  of  smallpox,  superficial  in  position 

Fig.  2,  Lesions  of  chickenpox  •.         .         .         .124 

CIX.  Chickenpox    ,         .         .         .         .         .         . 

ex.  Chickenpox    ....... 

CXI.  Chickenpox    ....... 

CXII.  Chickenpox    ....... 

CXIII.  Chickenpox  of  unusual  distribution 
CXIV.  Fig.    1,    Head   and   shoulders    of   a   woman    with 
chickenpox ;  Fig.  2,  A  papular  syphilide   . 
CXV.  A  papular  syphilide         .         .         .         .         .         .128 

CXVI.  A  papular  syphilide        ..... 

CXV  IT.  A  pustular  syphilide       ..... 

OXVIIL  {Stereoscopic.)     Acne      .         .         .         .         .         .140 

CXIX.  Fig.  1,  Acne;  Fig.  2,  Acute  eczema 
CXX.  Impetigo        ....... 

CXXI.  Fig.    1,    Lesions   of    impetigo ;     Fig.    2,    Pustular 
dermatitis         ....... 


LIST    OF    CHARTS 


CHART  PACE 

I.  Confluent  smallpox  with  severe  suppurative  fever         .  '     4 

II.  Discrete  smallpox  with  severe  suppurative  fever           .  34 

III.  Confluent  smallpox  with  moderate  suppurative  fever    .  35 

IV.  Severe    discrete    smallpox    with    moderate  secondnry 

fever 37 

V.  Confluent  smallpox  modified.     Severe  toxemic  fever   .  38 

VI.  Discrete  smallpox  with  long  pre-eruptive  period  .         .  62 

VII.  Discrete  smallpox  without  secondary  fever  ...  64 

VIII.  Variola  sine  eruptione         .         ....  .65 

IX.  Toxic  smallpox.     Temperature  low  .         .         .88 

X.  Toxic  smallpox.     Temperature  high    ....  88 

XI.  Toxic  smalljwx.     Low  terminal  temperature        .          .  89 

XII.  Toxic  smallpox.     High  terminal  temperature       .         .  89 

XIII.  Toxic  smallpox,     Toxaemic  pyrexia  distinct  from  sup- 

purative       ........  90 

XIV.  Statistical  chart  to  show  that  immunity  to  vaccinia  is 

acquired  coincidently  with  the  onset  of  smallpox     .  146 


2141 


THE 

DIAGNOSIS  OF  SMALLPOX 


CHAPTER     I 

INTRODUCTORY 

The  times  have  changed  since  the  days  of  Jenner.  Besides 
that  we  have  less  practice  in  the  art,  several  circumstances 
cause  the  diagnosis  of  smallpox  to  present  to  us  more 
difficulties  than  to  our  forefathers.  To  Jenner  we  owe  the 
chief  of  these  difficulties.  Through  him,  smallpox  has 
become  a  different  disease,  easier  to  suffer  but  harder  to 
distinguish ;  and  the  simple  rules  which  were  once  enough 
are  now  sometimes  apt  to  fail  us. 

Two- thirds  of  the  errors  in  the  diagnosis  of  smallpox 
arise  from  its  confusion  with  chickenpox.  Only  a  little  before 
Jenner's  time  did  chickenpox  come  to  be  distinguished  clearly 
from  the  graver  disease.  Indeed,  it  was  not  until  well  into 
the  nineteenth  century  that  the  identity  of  the  two  disorders 
ceased  finally  to  be  a  matter  of  serious,  controversy.  Even 
at  the  latter  end  of  the  century  Hebra  appeared,  like  a 
modern  Nestor,  maintaining  still  the  ancient  heresy.  That 
the  two  diseases  are  clinically  distinct,  that  they  are  distinct 
pathologically,  that  one  protects  in  no  degree  against  the 
other,  that  there  is  no  such  thing  as  a  hybrid  between  the 
two,  these  now  are  fundamental  axioms.  When  the  two 
things  were  accepted  as  the  same  and  no  necessity  arose 
for  their  distinction,  half  the  difficulties  of  diagnosis  had 
not  besfun  to  exist. 


2  THE    DIAGNOSIS    OF    SMALLPOX 

The 'importftn^e'.  of^' t^iW 'pi'oblem,  too,  has  immensely 
ijicreak^A "  (^nce'  il  wast  ev.e^ybbSy^  lot  to  get  smallpox, 
and  tiherG,waS^:littie'a,ttepipt'tG'' segregate  the  atflicted.  A 
yncofi^  '.(^piniGn  was  then  of  no  great  consequence,  and  an 
'Extreme  precision  of  diagnosis  was  hardly  worth  the  trouble 
of  attaining.  A  correct  opinion  and  an  early  opinion  are 
now  of  the  first  importance,  however  insignificant  may  be 
the  attack,  and  for  such  an  opinion  to  be  formed  a  close 
scrutiny  of  the  signs  and  symptoms  is  frequently  essential. 
But  before  proceeding  to  the  analysis  it  will  be  desirable 
to  make  a  preliminary  study  of  the  ground  to  be  surveyed. 

Of  rashes,  toxcemic  and  focal. — Everyone  recognises 
that  there  is  a  pathological  distinction  to  be  drawn  between 
such  a  rash  as  may  be  caused  by  eating  shell-fish  and 
the  skin-lesions  of  scabies  or  of  lupus.  The  one  is  pro- 
voked by  the  circulation  in  the  blood  of  a  chemical  poison, 
the  others  by  the  local  action  of  certain  parasites  in  the 
skin. 

A  similar  distinction  is  suggested  by  the  infectious 
exanthems  whose  eruptions  fall,  some  into  one  class,  some 
into  the  other.  The  vesicles  of  chickenpox,  perhaps  also 
the  rose-spots  of  enteric  fever,  are  caused  by  the  local 
action  of  certain  micro-organisms.  The  rashes  produced  by 
the  injection  of  the  antitoxin  of  diphtheria,  the  rash  of 
hsemorrhagic  diphtheria,  and  doubtless  the  rash  of  scarlet 
fever  also,  are  all  caused  by  the  circulation  in  the  blood 
of  peculiar  chemical  products. 

There  are  some  differences  in  the  clinical  symptoms 
which  commonly  accompany  the  two  kinds  of  rashes. 
What  may  be  called  the  focal  rashes  do  not  necessarily 
evoke  any  serious  constitutional  disturbance.  If  this 
occurs,  as  it  sometimes  does,  either  it  is  in  proportion  to 
the  extent  and  severity  of  the  focal  rash,  or  else  it  is  pro- 
voked by  another  cause.  On  the  other  hand,  the  toxemic 
rashes  are  commonly  accompanied  by  fever  or  by  constitu- 
tional disturbance  which  is  caused  by  the  same  poison 
whose  circulation  in  the  blood  produces  the  rash  itself 
The  toxsemic  rash  is  but  one  symptom  of  the  intoxication. 


INTRODUCTORY  3 

A  further  distinction  lies  in  the  fact  that  toxaemic 
rashes  are  generally  diffuse,  while  focal  rashes  are  commonly 
composed  of  circumscribed  lesions;  or  the  latter,  if  diffuse, 
are  unsymmetrical,  as  with  erysipelas.  But  the  point 
must  not  be  pressed,  since  circumscribed  lesions  are 
met  with  in  some  drug-rashes,  and  also  in  those 
toxoemic  rashes  which  are  made  up  of  small  haemorrhagic 
extravasations. 

The  exantheras,  then,  are  signalised  in  some  instances 
by  a  focal  rash,  in  others  by  a  toxsemic.  Smallpox, 
therefore,  is  exceptional ;  for  it  is  a  disease  which  presents 
examples  of  both  kinds  of  rash  and  exhibits  the  symptoms 
characteristic  of  each. 

The  variolous  rashes  and  febrile  states. — When  a  person 
falls  ill  with  smallpox  the  first  symptoms  are  those  of  a  general 
intoxication.  There  is  a  sudden  rise  of  temperature  and  the 
common  symptoms  of  a  febrile  toxaemia.  The  duration  of 
the  toxaemia  is  about  a  week,  and  during  its  course  the 
patient  may  develop  a  toxaemic  rash  of  one  kind  or  another. 
The  toxaemia  may  even  be  fatal;  in  that  case  the  patient 
is  said  to  die  of  haemorrhagic  smallpox.  This  variolous 
toxaemia  is  precisely  analogous  to  that  of  scarlet  fever, 
and  the  rashes  which  are  sometimes  evoked  by  the  former 
are  analogous  to  the  rash  which  is  characteristic  of  the  latter 
disease. 

If  this  were  all,  smallpox  would  be  a  disease  simple  to 
understand,  if  often  difficult  to  distinguish.  Its  peculiarity 
is  that,  half-way  through  the  primary  toxaemia,  a  focal 
rash  is  developed,  which  may  be  insignificant,  but  is  some- 
times so  severe  as  to  be  capable  itself  of  causing  serious 
illness  or  even  death.  The  focal  rash,  like  most  focal 
rashes,  consists  of  circumscribed  lesions  ;  and  the  constitu- 
tional effects  which  they  produce  are  in  direct  proportion 
to  their  number  and  severity.  A  boil  is  a  focal  lesion  in- 
considerable in  effect ;  but  if  the  body  were  covered  with  boils 
the  illness  to  which  they  would  give  rise  would  be  serious 
and  the  fever  considerable.  It  is  so  with  the  focal  rash 
and  secondary  fever  of   smallpox.     A  chart  is  reproduced 


4  THE    DIAGNOSIS    OF    SMALLPOX 

which  shows   the  distinction  between  the  two  fevers  whose 
combination  makes  the  complete  disease. 


Chart  i. — Confluent  Smallpox  with  Seveke  Suppurative  Feaer. 

The  secondary  fever  is  a  mere  fever  of  suppuration. 
The  focal  rash,  which  causes  it,  makes  its  appearance  on 
the  third  or  fourth  day  of  illness.  The  rash  consists 
of  a  number  of  skin-lesions  scattered  over  the  surface  of 
the  body,  each  of  which  is  the  seat  of  inflammation  so 
intense  as  to  lead  in  the  course  of  four  or  five  da3'^s  to 
the  formation  of  a  small  abscess.  Within  a  few  days 
more  the  contents  dry  up  or  are  partly  emptied  by  rupture. 
A  crust  forms  which  becomes  detached  when  the  lesion 
has  healed  and  leaves  a  small  scar  if  the  injury  was  deep 
enough.  The  number  of  lesions  which  are  present  may 
not  amount  to  a  dozen ;  or  there  may  be  many  thousands 
of  them,  and  they  may  be  set  so  closely  as  to  conceal 
almost  the  whole  cutaneous  surface. 

The   diagnosis  of   smallpox   turns   in   most  cases   upon 


INTRODUCTORY  5 

the  character  of  the  focal  rash.  The  evidence  presented 
by  the  rash  depends  partly  upon  the  anatomical  character 
of  the  mdividual  lesions,  partly  upon  their  disposition  in 
relation  to  the  surface  of  the  body,  that  is  to  say,  upon 
their  distribution.  It  has  been  the  accepted  teaching  to 
give  precedence  to  the  former  body  of  evidence.  That 
practice,  intelligible  in  years  gone  by  when  modified  small- 
pox was  the  exception,  is  now  less  easy  to  justify  when 
modified  smallpox  is  the  rule.  The  evidence  from  position, 
there  can  be  little  doubt,  is  in  most  cases  more  intrinsically 
valuable  than  the  evidence  from  character ;  it  is  certainly 
the  more  easily  observed  and  the  more  generally  de- 
pendable. In  the  chapters  which  follow,  therefore,  the 
salient  feature  of  the  disease,  the  focal  rash,  will  be  described 
first  to  the  exclusion  of  the  symptoms  of  the  toxjemia; 
and  the  distribution  of  the  rash  will  be  dealt  with  at 
some  length  before  an  attempt  is  made  to  indicate  the 
peculiarities  of  the  lesions  of  Avhich  the  rash  is  composed. 


CHAPTER     II 
DISTRIBUTION 

All  rules  have  exceptions,  although  if  we  but  knew  it 
there  should  be  a  reason  for  every  irregularity.  The  rules 
of  distribution  may  be  derived  from  an  examination  of  the 
rash  in  a  number  of  cases  of  smallpox;  but  in  certain 
cases  there  will  be  observed  some  very  remarkable  deviations 
from  the  common  pattern.  The  irregularities  to  which 
allusion  is  made  present  themselves  as  streaks  or  clusters 
of  closely-set  pustules,  for  the  existence  of  which,  however, 
there  is  generally  a  good  and  obvious  reason.  They  may 
be  called  irritation-patches.  Many  writers  on  the  subject 
have  referred  to  them.  But  to  regard  them  as  pathological 
curiosities,  merely,  would  be  a  cardinal  error,  for  by  the 
light  of  these  exceptional  instances  all  the  common  laws 
of  distribution  may  be  explained. 

Some  striking  examples  in  point  are  depicted  in  Plates  i. 
and  ir.  In  one  case  the  impression  of  a  mustard-leaf  came 
out  in  relief.  In  another  a  crop  of  pustules  matured  after 
an  injury  to  the  cheek.  A  not  infrequent  exciting  cause 
of  such  a  cluster  is  a  successful  vaccinal  inoculation  done 
during  the  period  of  incubation.  (Plate  i.,  Fig.  2.)  The 
patches  are  evoked  by  antecedent  irritation,  mechanical, 
chemical,  or  inflammatory.  They  may  be  of  any  size;  a 
patch  may  cover  a  square  foot  of  surface  or  an  area  no 
bigger  than  a  finger-nail,  the  less  conspicuous  instances 
being  relatively  common.  (Plates  x.,  Fig.  2,  xix.,  XL.,  and 
Lv.,  Fig.  2.) 

The  influence  of  dttire. — Even  more  interest  attaches 
to  the  curiosities  of  distribution  caused  by  the  friction  or 
intermittent  pressure  of  articles  of  clothing.  One  such 
instance  is  forcibly  illustrated  in  Plate  ii.  (Fig.   2),   which 


DISTRIBUTION  7 

exhibits  the  Hnes  of  friction  of  the  tape  and  towel  on  the 
abdomen  of  a  woman.  In  another  case  (Plate  iii.)  an 
eruption  of  unwonted  density  was  generated  by  irritation 
from  a  vest.  In  the  latter  case  the  patient  had  been  upon 
tramp,  and  the  effect  was  enhanced  by  a  sweaty  skin. 
Doubtless  the  influence  of  sweat  is  an  added  factor  in 
many  of  these  cases,  since  they  are  observed  more  often  in 
summer  than  in  winter.  Other  well-marked  examples  figure 
in  the  illustrations.     (Plate  iv.) 

Those  are  the  grosser  effects.  Minor  instances  of  the 
influence  of  attire  are  more  frequently  encountered.  The 
pressure  of  a  collar-stud,  friction  from  a  collar,  the  chafing 
of  the  underclothing  on  the  axillary  folds,  the  pressure  of 
the  corsets  against  the  sternum,  the  pressure  of  a  brace- 
button,  the  rubbing  of  the  stocking  or  garter  against  the 
hamstrings,  the  chafing  by  the  boot  of  the  tendo  Achillis 
or  of  the  tendons  along  the  front  of  the  ankle-joint;  some 
such  incidents  mark  their  effect  in  the  majority  of  cases 
of  smallpox,  and  many  secure  a  record  in  some  of  these 
plates.  (Plates  v.,  Fig.  1,  viii.,  Fig.  1,  ix..  Fig.  2,  x.,  Fig.  1, 
XIV.,  XVI.,  Fig.  2,  and  xxv.) 

Pathology. — Irritation-patches  are  liable  to  occur  on  any 
part  of  the  body.  They  are  not  determined  by  heat  or 
cold,  by  drought  or  moisture.  They  are  independent  of 
exposure  to  air  and  of  protection  by  clothing.  They  occur 
among  the  washed  and  among  the  unwashed,  and  on 
clean  parts  of  the  skin  as  well  as  on  dirty.  How  do  they 
happen  ?  The  factor  common  to  all  cases  is  a  disturbance 
in  the  balance  of  the  cutaneous  circulation.  And  from  the 
fact  that  the  blood-vessels  are  involved  essentially,  it  may 
be  inferred  that  the  infective  particles  are  blood-borne,  and 
that  the  focal  lesions  are  produced  by  the  precipitation  of  the 
particles  out  of  the  blood-stream  into  the  skin.  Smallpox, 
that  is  to  say,  in  its  pre-eruptive  stage,  is  a  septicaemia.* 

This  conclusion  is  in  harmony  with  what  can  be  deduced 

*  The  alternative  hypothesis  would  be  that  the  increased  activity  of  the 
cutaneous  circulation  manures  a  soil  already  containing  the  dormant  seeds  of 
disease,  most  of  which  would  otherwise  fail  to  germinate  and  fructify.     Stripped 


8  THE    DIAGNOSIS    OF    SMALLPOX 

as  to  the  most  favourable  time  for  the  effective  applica- 
tion of  the  irritant.  In  many  instances  it  has  operated  in 
the  course  of  or  before  the  period  of  incubation;  but  in  such 
cases  the  vascular  consequences  have  persisted,  or  have  been 
such  as  might  have  persisted,  until  the  onset  of  illness.  * 
And  in  other  cases  the  application  of  the  irritant  and  the 
onset  of  illness  have  been  actually  coincident ;  or  it  may 
be,  even,  that  the  former  has  not  long  preceded  the  outcrop 
of  the  rash. 

Less  obvious  is  the  exact  mechanism  by  which  the 
precipitation  is  effected.  An  adequate  explanation  of  an 
irritation-patch  may  be,  merely,  that  a  greater  volume  of 
blood  passes  through  the  capillaries  of  the  area  affected 
and,  therefore,  that  the  number  of  infective  particles  cir- 
culating in  that  area  is  proportionately  increased.  But 
mere  exuberance  of  blood-supply  is  probably  not  the  only 
determining  factor,  because  inflammation  of  the  skin  does 
not  necessarily  have  this  peculiar  effect;  moreover,  the 
relative  excess  of  eruption  is  often  out  of  all  proportion  to 
the  excess  in  blood-supply.  (Plates  ii..  Fig.  1,  and  iii.) 
An  ancillary,  if  not  the  essential  cause,  should  probably  be 
sought  in  some  of  the  concomitant  vascular  changes ;  in 
an  alteration  of  the  calibre  of  the  vessels,  in  a  change  in  the 
velocity  of  the  blood-stream,  or  even,  it  may  be,  in  a  morbid 

of  metaphor  and  stated  in  pathological  terms,  this  thesis  sounds  less  attractive. 
Moreover,  it  is  diflBcult  to  reconcile  with  the  facts  set  forth  in  the  rest  of  this 
chapter,  and  it  does  not  harmonise  with  any  tenable  theory  of  the  pathology  of 
the  disease. 

The  apparent  difficulty  of  reconciling  the  ordinary  phenomena  of  the  disease 
with  the  assumption  of  a  general  infection  by  a  single  micro-organism  has  led  to 
the  enunciation  of  various  hypotheses.  Thus  Birdwood  {Guy's  Hospital  lieports, 
Vol.  XLviii.,  1892)  assumed  smallpox  to  be  purely  a  skin-disease,  the  infection 
single  and  engrafted  from  without.  Perhaps  the  favourite  hypothesis  has 
been  that  which  assumes  a  general  specific  infection  predisposing  to  and  allow- 
ing of  a  secondary  infection  by  ordinary  pyogenic  organisinc,  to  which  the 
cutaneous  lesions  are  due  wholly  or  in  part.  Felix,  however  [Bulletin  de  la 
Soc.  Vaudoise  des  Sc.  Nat.,  Vol.  xxxix.,  1903),  suggested  a  double  simultaneous 
infection  through  the  mucous  membranes  by  a  specific  micro-organism  and  by 
unspecific  streptococci;  and  Washbourne  {Guy's  Hospital  Gazette,  Vol.  xv., 
1901)  suggested  a  similar  conjoint  infection  by  two  unknown  confederated 
organisms,  both  specific. 


DISTRIBUTION  9 

alteration  of  the  endothelial  wall.  The  mechanism  of  pre- 
cipitation must  be  something  in  the  nature  of  an  embolism. 
It  is  not  necessary  to  suppose  that  the  embolic  particle 
actually  blocks  the  vessel;  more  probably,  it  becomes 
attached  to  the  wall  of  the  capillary  loop  in  a  papilla.*  And 
what  would  best  conduce  to  that  event  would  be  not  so  much 
a  greater  flow  of  blood,  which  would  merely  cause  a  greater 
number  of  infective  particles  to  pass  through  the  loop  in  a 
given  time,  as  an  actual  slowing  of  the  current,  which  would 
assist  in  their  precipitation. 

Such  a  slowing  of  the  blood-current  occurs  during  inflam- 
mation, though  not  in  all  stages  of  it  nor,  necessarily,  in  all 
parts  of  the  inflamed  surface.  While  an  increased  velocity 
would,  in  itself,  cause  a  greater  difiiculty  in  the  deposition 
of  the  infective  particles,  too  great  a  slowing  or  an  actual 
stoppage  of  the  current,  by  stopping  the  circulation  of  the 
infective  material,  would  tend,  unless  the  particles  were 
present  in  inordinate  numbers,  to  precisely  the  same  result. 
In  fact,  evidence  is  sometimes  presented  that  blood-stasis 
is  unfiivourable  to  the  development  of  the  rash.  A  strong 
stimulus — for  example,  that  of  a  mustard-leaf — may  cause  an 
actual  blood-stasis  and  determine  an  absence  of  the  rash  over 
the  area  of  application.  The  point  receives  illustration  in 
Plate  v.,  Fig.  2.     (See  also  Chapter  X.,  p.  69.) 

Cutaneous  stimvlation. — In  many  of  the  instances  where 
an  aggregation  of  pustules  can  be  observed,  the  skin  has  been 
irritated  but  not  inflamed.  In  many  cases  the  irritation  was 
so  slight  that  the  patient  was  unconscious  of  it,  though  the 
position  of  the  patch  on  some  part  of  the  surface  which  is 
commonly  exposed  to  friction  demonstrates  the  cause  of  its 
origin.  To  the  production  of  a  temporary  or  of  a  periodical 
slowing  of  the  capillary  blood-current,  actual  inflammation, 
indeed,  is  by  no  means  necessary.  Mere  stimulation  of  the 
skin   causes    first   contraction,   then    expansion,   and    lastly 

•  It  does  not  follow  that  such  a  particle  must  have  an  excessive  minuteness. 
^y  agglutination  into  a  clump,  and  by  an  aggregation  of  leucocytes  around 
such  a  clump,  a  mass  might  be  formed  sufiBcient  even  for  the  occlusion  of  a 
vessel. 


10  THE    DIAGNOSIS    OF    SMALLPOX 

re-contraction  of  the  arterioles.  And  a  stimulus,  constantly 
repeated,  will  cause  the  blood-vessels  so  to  oscillate  that  there 
will  be  an  alternation  of  an  increased  and  a  diminished 
velocity.  Doubtless  in  most  of  these  cases  such  a  periodical 
slowing  of  the  current  is  the  determining  factor. 

The  converse  holds  good.  During  the  earliest  stage  ot 
the  illness,  if  a  part  of  the  skin  be  artificially  protected  from 
stimulation,  that  part  will  become  liable  to  the  eruption  in 
less  degree  than  the  corresponding  area  on  the  other  side 
of  the  body.  Convincing  illustrations  of  this  fact  are  not  of 
frequent  occurrence.  They  may  be  encountered,  sometimes, 
when  the  patient  has  fallen  ill  of  smallpox  while  under 
surgical  treatment  for  another  malady.  Under  such  circum- 
stances a  sparse  eruption  is  apt  to  be  developed  on  the  part 
covered  by  the  dressing ;  but  the  dressing  must  not  have 
been  irritative,  nor  must  the  part  have  been  inflamed.  Again, 
when  a  patient  comes  under  treatment  before  the  outcrop  is 
complete,  it  is  sometimes  possible  to  produce  the  same  effect 
by  design ;  but  under  such  circumstances,  as  might  be 
expected,  a  conspicuous  contrast  is-  not  easy  to  obtain. 
Plate  VI.  represents  the  issue  of  such  an  attempt.  A  case 
seized  at  the  very  onset  of  the  illness  would  doubtless  display 
a  more  striking  result. 

Now  let  the  assumption  be  made,  that  to  influence  the 
disposition  of  the  eruption  does  not  require  an  extra- 
ordinary stimulus  or  a  state  of  inflammation,  but  that  the 
trivial  kinds  of  stimulation  to  which  the  skin  is  ordinarily 
subject  may  upset  the  balance  of  the  capillary  circulation 
sufficiently  to  enhance,  however  slightly,  the  susceptibility  of 
the  overlying  skin.  Let  it  be  assumed,  further,  that  if  the 
skin  be  screened,  even  imperfectly,  from  stimulation,  a 
contrary  effect  will  be  produced.  It  should  then  follow 
that  evidence  of  the  operation  of  these  laws  should  be 
forthcoming,  not  merely  by  a  freak  of  fortune  in  the  ex- 
ceptional case,  but  also  in  the  case  of  common  sort  which 
may  come  under  notice  to-morrow.  And  that  is  just  what 
happens.  Broadly  speaking,  the  hollows  and  shallows  of  the 
surface  tend  to  escape  the  rash  at  the  expense  of  the  ridges 


DISTRIBUTION  11 

and  prominences.  Conspicuous  illustrations  of  the  state- 
ment are  furnished  in  Plate  vii.  In  those  instances,  the 
prominence  merely  of  a  tendon  was  sufficient  to  attract 
along  its  contour  a  few  out  of  the  scanty  stock  of  pustules 
with  which  the  patient  was  endowed.  The  connection 
between  cause  and  etl'ect  is  not  always  so  clear,  but  a  little 
research  will  generally  reveal  it.  On  account  of  the  well- 
marked  prominences  and  depressions  which  it  displays,  per- 
haps the  facts  can  most  readily  be  demonstrated  on  the  loot. 

Distribution  on  the  foot  and  hand. — Relatively  to  the 
rest  of  the  body,  the  foot  is  very  inconstant  in  its  suscep- 
tibility to  the  eruption.  This  is  doubtless  due  in  part  to 
differences  in  the  comfort  of  the  boot ;  but  a  disturbing 
factor  even  more  cogent  is  the  variety  in  the  habits  of  the 
patient.  One  who  walks  much  will  get  on  the  foot  a 
relatively  thicker  rash  than  the  patient  of  a  sedentary  life. 
And  he  will  come  worse  off  than  either  who,  unused  to 
much  walking,  takes  to  the  road  just  before  he  falls  ill. 
Such  factors  influence  not  only  the  amount  of  the  eruption, 
but  also  its  disposition.  In  most  cases,  the  back  of  the 
foot  suffers  more  than  the  sole  (Plates  iv..  Fig.  2,  and 
VIII.) ;  but  overmuch  standing  or  walking  is  apt  to  evoke 
an  eruption  of  extraordinary  profuseness  on  the  soles,  round 
the  margins  of  the  soles,  and  over  the  toes.     (Plate  ix.) 

Whatever  the  relative  density  may  be  on  the  back  of 
the  foot  and  on  the  sole,  very  few  spots  are  developed 
between  the  toes,  or  in  the  folds  beneath  the  toes ;  for 
these  are  sheltered  places.  Similarly,  the  shallow  over  the 
heads  of  the  metatarsal  bones  tends  to  escape,  and  the 
hollows  behind  the  malleoli,  and  the  arch  beneath  the  foot. 
(Plate  VIII.  and  Plate  iv..  Fig.  2.)  A  dirty  foot  is  a  good 
teacher :  where  the  dirt  sticks,  from  those  places  is  the  rash 
averse ;  where  the  dirt  gets  rubbed  away,  there  the  rash 
comes  thicker.  The  instep,  especially  the  tendinous  ridges 
and  the  bony  eminences,  the  tendo  Achillis  (Plate  x..  Fig.  1), 
the  backs  of  the  toes,  the  heel,  the  balls  of  the  toes,  and 
the  toe-pads  (Plate  ix.),  some  or  all  of  these  the  rash 
takes  for  its  chosen  habitations. 


12  THE    DIAGNOSIS    OF    SMALLPOX 

Standing  out  as  pronounced  exceptions  to  the  rule,  the 
malleoH,  in  many  instances,  enjoy  a  comparative  immunity. 
(Plates  VIII.,  Fig.  2,  and  ix.,  Fig.  2.)  When  low  shoes  are 
worn,  the  malleoli  are  subject  to  the  common  law.  (Plate  ix., 
Fig.  1.)  The  exceptional  instances  occur  among  those  who 
wear  a  well-fitting  boot.  In  a  foot  so  encased,  the  malleoli 
suffer  but  little  friction  with  the  leather,  since  they  are 
situated  at  the  fulcrum  of  the  lever  ;  and  since  they  are 
protected  by  the  leather  from  extraneous  friction,  they 
are  correspondingly  protected  from  the  rash.  Some  other 
differences  may  generally  be  noticed,  according  as  the 
patient  has  worn  boots  or  shoes.  Round  and  above  the 
ankle,  in  the  latter  case,  th&  disposition  of  the  rash  is 
influenced  by  such  agencies  as  the  friction  of  the  sock,  of 
the  trouser-ends,  of  the  skirts ;  and  though  the  incidence 
of  the  rash  may  be  less  or  greater,  according  to  the 
circumstances  of  the  case,  its  disposition  differs  in  kind 
from  that  which  would  be  produced  by  the  boot  itself. 

In  spite  of  a  general  similarity,  hardly  two  feet  are  alike 
in  the  precise  manner  in  which  the  eruption  is  disposed. 
Account  must  be  taken  of  differences,  not  only  in  the  habits 
of  the  patient  and  in  the  foot-gear,  but  also  in  the  conforma- 
tion of  the  foot.  The  concavity  of  the  sole  will  suffer 
relatively  less  among  those  with  high-arched  feet  (Plates  iv., 
Fig.  2,  and  ix..  Fig.  1)  than  among  the  flat-footed.  (Plate  x., 
Fig.  1.)  The  backs  of  the  toes,  as  well  as  their  extensor 
tendons  in  their  course  over  the  bases  of  the  proximal 
phalanges,  will  be  more  subject  to  friction  among  the 
claw-toed  and  wiU  earn  a  thicker  rash.  (Plate  ix.,  Fig.  2.) 
The  malleoli,  again,  and  the  tendinous  ridges  of  the  foot 
vary  in  prominence  in  different  persons,  and  produce  a 
correspondingly  variable  effect.  In  general,  a  plump  foot 
shows  in  the  disposition  of  the  eruption  less  conspicuous 
contrasts  than  a  thin  one. 

Because  of  the  more  even  contour,  the  contrasts  dis- 
played by  the  hand  and  forearm  are  much  less  pronounced. 
(Plates  x..  Fig.  2,  and  xlvi.)  They  may  be  distinct 
enough  when  the  hand  has  prominent  bony  and  tendinous 


PLATE    I. 


Fig.  1.— A  nnistard-leaf  was  applied  to  the  chest  at  the  onset  of  the  illness,  ta 

relieve  the  epigastric  pain  which  was  one  of  the  symptoms. 
Fig.  2. — The  patient,  whose  attack  was  a  mild  one,  was  successfully  vaccinated 
during  the   period   of  incubation.     The  four  large  pustules  are  those  of 
^  vaccinia  ;  the  smaller  ones  clustering  round  them  are  variolous. 


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PLATE  IV. 

Fig.  1. — The  ring  of  pustules  below  the  knee  was  caused  by  the  pressure  of  a  garter.  Such 
an  effect  is  not  very  infrequent. 

Fig.  2. — The  patient  was  a  street  urchin.  The  attack  was  not  severe.  The  clustering  of 
pustules  above  the  ankle  was  brought  about  by  the  flapping  of  his  ragged  trouser- 
ends  against  the  bare  leg.  The  case  furnished  a  good  example  of  the  method  of 
distribution  on  a  well-shaped  foot.  It  will  be  noticed  that  on  the  inner  side  of  the 
sole,  where  the  arch  was  most  pronounceil,  the  rash  was  very  scanty.  It  was 
thickest  on  the  balls  of  the  toes  and  on  the  heels;  but  in  those  situations,  on 
account  of  the  thickness  of  the  cuticle,  the  eruption  is  not  very  clearly  indicated. 


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PLATE   VII. 

Tlie  figures  show  the  lesions  arranged  along  the  extensor  tendons  of  the  foot 

and  hand. 


PLATE   VIII. 

Fig.  1.— Rash  disposed  characteristically  on  the  back  of  the  foot.  The  lesions 
were  strewn  thickest  over  the  tendons  in  front  of  the  ankle-joint.  The 
cluster  (a)  was  caused  by  the  constriction  of  the  boot-lace.  The  shallow 
groove  (//)  over  the  heads  of  the  metatarsal  bones  was  wholly  bereft. 

Fig.  2. — Inner  side  and  sole  of  the  foot  of  the  same  patient.  As  happens  often, 
the  sole  almost  wholly  escaped.  The  rash  was  attracted  to  the  back  and 
sides  of  the  heel,  but  not  to  the  groove  beneath  the  malleolus  (a).  The 
patient  wore  boots,  and  it  will  be  noticed  that  no  lesions  appeared  on 
the  point  of  the  malleolus  (J). 


PLATE   X. 

Fig.  1. — The  patient  was  flat-footed,  and  the  eruption  on  the  sole  was  there- 
fore distributed  at  random.  As  happens  frequently,  the  pressure  of  the 
boot  caused  a  cluster  of  lesions  to  appear  over  the  tendo  Achillis  {a). 

Fig.  2. — The  print  shows  the  eruption  disposed  chiefly  on  the  back  of  the  hand 
and  over  the  knuckles  and  on  the  backs  of  the  fingers.  Between 
the  fingers  the  spots  are  fewer.  A  cluster  of  pustules  (a)  was 
provoked  by  a  sore  on  the  wrist.  It  will  be  noticed  that  the  rnsh  was 
deficient  along  the  radial  edge  of  the  forearm,  but  a  little  accented 
along  the  ulnar  edge  of  the  forearm  and  hand.  This  edge  suifers  most 
in  some  cases ;  in  others,  that ;  whilst  in  some  instances  the  rash  is 
equally  pronounced  on  each.  This  variety  has  much  to  do  with 
differences  of  activity  and  occupation.  Friction  with  the  table,  the 
desk,  or  the  bench  would  attract  the  rash  to  the  ulnar  edge ;  freer  and 
more  active  movement  of  the  arm  would  attiact  it  to  the  radial  edge, 
which  would  be  the  more  involved  in  friction  with  the  sleeve  (compare 
Plates  xvii.,  Fig.  1,  and  XLVi.). 


PLATE  X. 


PLATE    Xt. 

Fig.  1.— This  is  from  the  same  arm  as  that  depicted  in  Plate  xvii.,  Fig.  1,  and  shows  a 
characteristic  disposition  of  the  rash  on  the  flexor  surfaces  of  the  forearm  and  hand. 
The  rash  was  more  scanty  on  the  hand  than  on  the  forearm.  In  the  former  situation 
the  spots  are  difficult  to  discern,  since  they  were  obscured  by  the  thick  cuticle  of 
the  palm.  On  the  hand  they  were  most  numerous  on  the  thenar  and  hypothenar 
eminences,  and  were  not  developed  in  the  palmar  hollow.  The  eruption  was 
aggravated  at  the  flexure  of  the  wrist  (a) ;  this  point  is  illustrated  again  in  the 
next  figure. 

Fig.  2.— Unusual  arrangement  of  the  lesions  on  the  palm.  The  spots  lie  along  the  hollow  of 
the  palm  on  either  side  of  the  line  a  b.  It  is  easy  to  see  that  this  arrangement 
was  brought  ^ibout  by  holding  a  tool. 


DISTRIBUTION  13 

ridges,  but  if  it  is  smooth  and  plump  the  distribution 
may  be  singularly  even.  The  extensor  surface  sutlers 
most,  and  the  palm  of  the  hand  is  generally  compara- 
tively immune.  (Plates  xi.,  Fig.  1,  and  xvii.,  Fig.  1.) 
The  rash  tends  to  be  most  pronounced  on  the  back  of  the 
wrist  and  hand  and  over  the  heads  of  the  metacarpals, 
since  those  parts  are  the  most  exposed.  In  many  cases 
the  rash  is  accented  alonjr  the  radial  or  ulnar  edge  of  the 
forearm,  or  along  both ;  and  at  the  flexure  of  the  wrist  it 
is  sometimes  exaggerated  on  account  of  the  rubbing  of  the 
sleeve.  The  incidence  is  distinctly  less  between  the  fingers 
than  along  their  backs,  and  in  the  hollow  of  the  palm 
than  on  the  muscular  eminences  which  bound  it.  The 
precise  disposition  in  a  particular  case  depends  a  good  deal 
upon  the  patient's  occupation.     (Plate  xi.,  Fig.  2.) 


CHAPTER  III 

DISTRIBUTION    (continued) 

Scheme  of  distribution. — Given  that  the  pattern  of  the  erup- 
tion on  the  foot  is  moulded  ahnost  wholly  by  circumstances, 
is  it  probable  that  the  general  scheme  of  distribution  on  the 
rest  of  the  body  is  governed  by  an  arbitrary  and  conventional 
rule  ?  The  facts  are  not  so ;  the  greater  includes  the  less,  and 
the  laws  which  are  effective  for  the  part  are  valid  for  the 
whole.  The  operative  causes  are  manifold ;  but  the  most 
potent  factors  are  exposure  to  air  and  friction  with  clothing, 
and  to  their  efficacy  every  case  of  smallpox  is  a  testimonial. 

The  brunt  of  the  attack  falls  upon  the  face  and  hands. 
(Plate  XII.)  These  are  just  those  parts  of  the  skin  where 
disfigurement  can  be  worst  endured,  since  they  are  kept 
habitually  uncovered.  And  it  is  because  they  are  unclad 
that  they  suffer  exceptionally;  for  they  are  exposed  thereby 
to  unceasing  stimulation  from  wind  and  weather,  from 
changes  of  temperature,  and  from  manipulation.  The  face 
is  exposed  the  more  constantly,  and  it  exceeds  the  hand  also 
in  its  blood -supply ;  more  infective  particles  pass  through 
the  vessels  of  a  given  area,  and  they  have  a  greater  chance  of 
precipitation.  For  these  reasons  the  incidence  on  the  face  is 
greater  than  on  any  other  part  of  the  body. 

On  the  covered  parts  distribution  is  most  influenced  by 
friction  with  the  clothing,  and  friction  is  determined  by 
movement.  Of  the  three  members — the  upper  limb,  the 
lower  limb,  the  trunk — the  first  is  the  most  mobile  and  the 
most  moved,  and  it  sustains  the  thickest  rash.  (Plates  xiii., 
Fig.  2,  and  xix.)  In  mere  amplitude  of  movement  the 
lower  limb  surpasses  the  trunk ;  but  the  trunk,  as  a  rule,  is 
in  more  constant  though  in  more  restricted  motion.  Hence 
the  leg,  in  most  cases,  is  less  susceptible  than  the  trunk. 

11 


DISTRIBUTION  15 

A  striking  characteristic  of  the  disease  is  that  the  back 
and  front  of  the  trunk  are  very  differently  affected.  The 
bulk  of  the  rash  is  found  behind.  In  front  it  is  more  sparse 
than  on  any  other  large  part  of  the  surface.  (Plates  xviil 
and  XIX.)  This  peculiarity  of  distribution  is  very  easy  to 
understand  by  considering  the  shape  and  habit  of  the  body. 
The  flexure  of  the  spine  looks  forward.  Nearly  every  move- 
ment, especially  with  the  more  laborious  forms  of  toil, 
involves  the  dorsal  arch  in  friction  with  the  underclothing. 
The  shoulders,  indeed,  sustain  an  amount  of  friction  but 
little  less  than  that  suffered  by  the  arm,  and  it  is  over  the 
shoulders  that  the  rash  comes  thickest.  (Plates  xiii,  and  xiv.) 
The  pivot  on  which  the  trunk  moves  is  the  pelvis.  In  the 
movements  of  the  trunk,  the  nearer  to  the  pivot  the  less  is 
the  amplitude  of  motion.  The  eruption,  therefore,  grows 
less  from  the  shoulders  downwards,  the  difference  being 
sometimes  pronounced  and  generally  distinct.  The  rash  is 
least  across  the  loins,  and,  as  might  be  supposed,  its 
incidence  again  increases  over  the  buttocks.  In  front  there 
is  a  similar  gradation,  but  it  is  more  constant  and  con- 
spicuous. In  a  case  of  confluent  smallpox,  even,  the  rash 
may  become  excessively  attenuated  on  the  lower  part  of  the 
abdomen.    (Plates  xv.,  xvi..  Fig.  1,  and  xxii.,  Fig.  2.) 

On  the  limbs  there  is  a  lineal  gradation  of  density 
similar  to  that  which  occurs  upon  the  trunk.  The  limbs 
have  most  mobility  at  their  distal  ends,  and  the  rash  increases 
in  density  from  above  downwards.  (Plates  xii.,  xv.,  and 
XXIV.)  This  centrifugal  distribution  is,  in  most  cases, 
particularly  well  displayed  upon  the  arms. 

A  characteristic  tendency  of  the  rash  is  to  shun  the 
most  sheltered  parts  of  the  cutaneous  surface.  These  are 
the  great  flexures  of  the  body.  The  armpit,  perhaps,  of  all 
parts  is  the  most  efficiently  screened,  and  consistently  enjoys 
an  immunity  which  is  virtually  complete.  (Plates  xviii. 
and  XXII.,  Fig.  2.)  An  immunity  hardly  less  ample  is  shared 
by  the  groins  and  the  hypogastrium.  (Plate  xvi.,  Fig.  1.) 
The  flexures  of  the  limbs  are  very  imperfectly  protected,  but 
in  the  bend  of  the  elbow  and  in  the  popliteal  space  it  is  the 


16  THE    DIAGNOSIS    OF    SMALLPOX 

rule  for  the  rash  to  be  noticeably  less  dense  than  on  contiguous 
parts  of  the  skin.     (Plates  xvi.,  Fig.  2,  and  xvii.,  Fig.  1.) 

Just  as  the  Hexures  are  relatively  secure  against  the 
rash,  the  counter-parts  on  the  extensor  surfaces  earn  a  dis- 
proportionate share.  The  elbow  is  peculiarly  apt  to  display 
a  thick  crop.  (Plate  xvii.,  Fig.  2.)  Similarly  the  rash  is 
denser  over  the  deltoid  and  on  the  outer  surface  of  the  arm 
than  on  the  inner  side  which  comes  against  the  chest  wall 
(Plates  XVIII.  and  xix.);  it  is  thicker  on  the  extensor 
surface  of  the  fore-arm  than  on  the  flexor :  thicker  on  the 
back  of  the  hand  than  on  the  palm.  On  the  leg  and  thigh, 
which,  being  less  active  than  the  arm,  sustain  a  more  scanty 
rash,  the  disposition  of  the  rash,  for  precisely  that  reason, 
presents  less  conspicuous  contrasts;  but  the  contrasts  exist 
and  are  in  the  same  direction.     (Plate  xx.) 

The  broad  features  of  distribution  are,  therefore,  that  the 
rash  prefers  the  upper  half  of  the  body  to  the  lower,  that  it  is 
a  rash  of  the  face  and  arms  rather  than  of  the  trunk  and  legs, 
that  it  is  a  rash  of  the  distal  ends  of  the  limbs  rather  than 
of  the  proximal,  of  the  back  of  the  trunk  rather  than  of  the 
front,  of  extensor  surfaces  rather  than  of  flexor,  and  that  it 
is  a  rash  which  shuns  the  most  pronounced  flexures. 

The  disposition  in  detail. — In  the  last  chapter  a  descrip- 
tion was  given  of  the  detailed  disposition  of  the  rash  on  the 
foot  and  hand.  Those  finer  shades  of  contrast,  though  they 
may  be  deemed  of  little  moment,  become  of  the  first  im- 
portance in  appropriate  cases,  and  it  is  necessary  to  take  a 
careful  account  of  them.  But  it  is  not  on  the  limbs  so  much 
as  on  other  parts  of  the  body  that  they  assume  their 
greatest  practical  value. 

On  the  face,  though  there  is  a  superficial  uniformity  of 
distribution,  a  closer  examination  reveals  the  choice  of  the 
rash  for  the  more  exposed  and  prominent  parts  in  contrast 
to  the  more  sheltered.  (Plates  xxi.  and  xxii.,  Fig.  1.)  Its 
aggregation  about  the  forehead,  nose,  and  malar  prominences 
causes  it  to  be  apportioned  unequally  from  above  down- 
wards. A  line  drawn  from  the  meatus  of  the  ear  to  the  ala 
of  the  nose  divides  the  face  into  two  parts,  on  the  lower  of 


DISTRIBUTION  17 

which  the  rash  is  noticeably  less  dense.  The  region  most 
screened  from  irritation  is  the  orbit,  and  there  the  rash  is 
relatively  sparse.  Even  the  depression  of  the  temple  com- 
monly wards  off  a  fraction  of  its  proper  share.  Under  the 
chin  the  rash  is  more  scanty  than  above  (Plate  xxv.), 
but  the  extent  to  which  the  submaxillary  region  suffers 
depends  upon  the  amount  of  fat  under  the  chin,  upon  the 
conformation  of  the  jaw,  and  upon  the  habits  of  the  patient. 
Little  children  and  people  with  a  double  chin  may  develop 
an  abundant  eruption  below  the  jaw. 

The  ear  commonly  displays  the  rash,  the  exposed  surface 
more  than  the  back  of  the  shell  The  lesions  are  set  along 
the  edge  of  the  shell  and  along  the  convexities  of  its  folds 
rather  than  in  the  grooves  between  them.  (Plate  xxii.,  Fig.  1.) 
The  prominence  of  the  mastoid  does  not  generally  escape,  but 
the  skin  in  the  angle  behind  the  ear  is  sheltered  by  the 
ear  itself,  less  or  iriore  successfully  according  as  the  shell  is 
prominent  or  retracted.  More  conspicuous  is  the  relative 
immunity  of  the  groove  beneath  the  lobule. 

The  neck,  lying  sheltered  between  the  protuberance  of 
the  head  above  and  of  the  shoulders  below,  is  less  subject 
to  the  rash  than  either.  In  some  cases  the  neck  is 
encircled  by  a  distinct  line,  above  and  below  which  there 
is  a  pronounced  contrast  in  density.  (Plates  XLViii.  and  liv.. 
Fig.  1.)  Such  a  line  marks  off  the  part  covered  by  clothing 
from  that  exposed  to  the  air.  In  most  cases  this  contrast  is 
wanting  or  inconspicuous. 

The  back  of  the  neck  suffers  most  (Plate  xxii..  Fig.  1.) 
In  front,  the  muscular  and  tendinous  and  bony  ridges  at  the 
root  of  the  neck  present  in  appropriate  cases  peculiarly 
valuable  opportunities  of  contrast.  (Plates  xxiii.  and  xxv.) 
Even  when  the  rash  is  relatively  scanty,  it  is  readily  seen  to 
pick  out  the  sterno-raastoid  and  its  prominent  tendons,  and 
the  edge  of  the  trapezius,  and  to  avoid  the  suprasternal, 
supraclavicular,  and  even  the  infraclavicular  hollows.  Along 
the  ridge  of  the  clavicle,  curiously,  the  rash  is  often  less 
pronounced  than  might  be  expected. 

It  will  be  noticed  that  the  flank,  lying  sheltered  beneath 


18  THE    DIAGNOSIS    OF    SMALLPOX 

the  arm,  suffers  less  from  the  rash  than  those  parts  of  the 
chest-wall  which  adjoin  it  in  front  and  behind,  (Plate 
XXII,,  Fig.  2.)  When  the  patient  is  well-built,  the  rash  is 
distributed  differently  over  the  prominent  scapular  regions 
and  in  the  interscapular  groove  (Plate  xiii.),  over  the  swell- 
ing pectorals  and  in  the  sternal  hollow.  (Plate  xxii.,  Fig.  2.) 
Exceptionally  the  lines  of  the  ribs  even  are  mapped  out. 
(Plate  xiv.) 

Anomalies  of  distribution. — If  habit  of  life  and  con- 
formation of  body  are  the  chief  determining  factors,  why 
is  not  variety  in  distribution  commensurate  with  the  variety 
of  form  and  habit  among  the  people  ?  A  considerable 
divergence  from  the  normal  is  seen  occasionally  when  the 
whole  mode  of  life  is  unusual,  for  example  in  the  case  of 
a  bed-ridden  paralytic  or  of  a  young  infant.  Yet  the 
difficulty  is  rather  to  explain  the  variations  Avhich  occur 
in  common  cases  than  to  account  for  the  prevailing 
uniformity.  For  whatever  the  habit  of  the  individual,  the 
relative  activity  of  different  parts  of  the  body  is  much 
the  same  in  all.  Clerk  and  navvy,  alike,  keep  the  face 
uncovered,  the  arms  more  active  than  the  trunk,  the  back 
more  exposed  to  friction  than  the  chest  and  abdomen.  It 
must  be  remembered,  too,  that  for  the  skin  to  be  irritated 
requires  that  it  shall  not  have  become  inured  to  the  irritant. 
Manual  labour  is  less  hurtful  to  the  workman's  palm  than  to 
the  hand  of  the  clerk.  The  ever-varying  frictions  and  irrita- 
tions falling  hourly  on  the  skin  count  more  than  the  habitual 
frictions  to  which  it  is  inured.  And  again,  when  the  onset 
has  been  sudden  and  the  illness  severe  enough  to  interrupt  his 
mode  of  life,  it  is  of  paramount  importance,  not  so  much  what 
the  patient  was  doing  when  full  of  vigour  yesterday,  as  what 
he  does  to-day  when  his  vessels  contain  the  infective  particles. 

The  trunk,  of  all  parts,  displays  the  most  variety  in  its 
liability.  The  relative  density  of  the  rash  on  the  back, 
chest,  abdomen,  is  almost  invariably  maintained ;  but  instead 
of  coming  next  to  the  arms  in  its  aptitude  for  the  rash,  the 
back  bears,  in  some  cases,  a  crop  which  is  relatively  in- 
conspicuous.    Women  and  children  are  most   apt  to   show 


DISTRIBUTION"  19 

this  peculiarity.  (Plates  xrii.,  Fig.  2,  and  xxiv.)  The  prob- 
able cause  of  it  is  that  men  lead  a  more  active  life,  while 
women  keep  the  movements  of  the  trunk  restrained  and  its 
surface  protected  by  the  use  of  corsets.  In  the  case  of  a  fat, 
sweaty  woman,  or  with  a  patient  whose  corsets  do  not  fit, 
the  corsets  may  have  an  opposite  effect  and  induce  the 
development  of  a  rash  out  of  proportion  in  its  density. 
(Plate  XXV.)  The  use  of  corsets,  and  their  fit,  influence 
also  the  incidence  of  the  rash  on  the  abdomen,  but  in  this 
instance  what  counts  more  is  the  shape.  Patients  with  thin 
retracted  abdominal  walls  are  less  likely  to  suffer  than  the 
fat-bellied. 

There  is  less,  but  still  considerable,  variety  in  the  relative 
incidence  on  the  leg.  This,  again,  is  an  effect  of  activity 
and  dress  by  which  women  come  off  the  best.  Children 
are  ape-like  in  the  relative  activity  of  the  lower  limbs, 
and  there  is  often  little  to  choose  between  the  density 
on  their  legs  and  on  their  arms.    (Plates  xv.  and  xxiv.) 

Striking  variations  occur  in  the  gradations  of  density 
along  the  length  of  the  limbs.  The  rule  is  for  the  density 
to  increase  from  above  downwards.  From  such  differences  as 
there  may  be  in  the  habits  of  a  workman,  of  a  woman  of 
inactive  life,  or  of  a  child-in-arms,  the  contrasts  of  the 
normal  centrifugal  disposition  may  be  either  exaggerated  or 
repressed.  What  is  more  surprising  is  that  sometimes  there 
is  an  actual  reversal,  so  that  the  density,  as  with  chickenpox, 
increases  from  below  upwards.  (Plate  xxvi.)  Such  a  re- 
versal is  the  more  important  when  it  is  found  on  the  arms. 
It  is  most  apt  to  occur  in  cases  of  modified  ^smallpox.  It 
is  not  very  infrequent,  and  usually  a  reference  to  the  habits 
of  the  patient  does  not  explain  it,  so  that  it  may  be  a  real 
disturbing  factor  in  diagnosis. 

Under  such  circumstances,  the  rash  may  never  reach 
the  hand ;  but  there  are  other  cases  in  which,  while  the 
arm  and  forearm  exhibit  the  normal  gradation,  the  hand 
alone  enjoys  a  relative  immunity.  (Plates  xviii.  and  xix.) 
In  rare  cases  there  is  a  reversal  of  the  order  of  incidence 
on  the  extensor  and  tiexor  surfaces  of  the  arm. 


20  THE    DIAGNOSIS    OF    SMALLPOX 

Partly  that  our  knowledge  of  causes  is  imperfect,  and 
partly  because  we  cannot  hope  to  elicit  all  the  pertinent  facts 
in  every  case,  it  is  too  much  to  expect  an  explanation  of 
all  such  vagaries.  Yet  the  exceptional  cases  are  fewer  and 
less  misleading  than  they  would  be  if  we  considered  dis- 
tribution to  be  governed  by  an  unknown  law  or  by  an 
empirical  rule.  And  if  a  discrepancy  occurs  in  the  evidence 
derived  from  a  part  of  the  eruption,  it  will  be  corrected 
by  the  accumulated  testimony  of  the  whole. 

The  finer  details  of  distribution  exhibit  similar  differences, 
and  similar  considerations  apply.  A  particular  prominence 
or  depression  will  not  be  similarly  affected  in  all  cases. 
Very  much  will  depend  upon  the  conformation  of  parts  in 
each  particular  case.  Because  a  few  spots  are  seen  in  the 
armpit,  because  the  orbit  is  filled,  or  because  the  rash  is 
undeveloped  on  a  tendinous  or  bony  ridge,  that  is  no  bar 
to  a  diagnosis  of  smallpox.  What  is  to  the  point  is  that, 
taken  as  a  whole,  the  protected  areas  are  deficient  in 
eruption  relatively,  and  the  more  so  in  proportion  to  the 
degree  of  protection. 

The  scalp  and  air-passages. — Patients  differ  widely  in 
the  susceptibility  of  the  scalp.  In  some  cases  it  rivals 
the  face,  in  others  it  almost  wholly  escapes.  Other  causes 
contribute  to  this  difference,  but  the  most  telling  is  the 
effectiveness  of  the  hairy  covering.  Bald-headed  people  come 
off  the  worst. 

The  mucous  membranes  of  the  air-passages  are  subject  to 
the  eruption,  the  visible  parts  most  liable  to  it  being  the  hard 
palate,  the  tip  and  edges  of  the  tongue,  and  the  pillars  of  the 
fauces.  Different  patients  show  remarkable  differences  in  the 
susceptibility  of  these  structures.  In  cases  of  equal  severity, 
the  lesions  may  be  few  or  absent,  or  the  mouth  and  throat  may 
be  covered  by  a  confluent  rash  which  may  extend  into  the 
larynx  and  trachea.  Notoriously  the  mucous  membranes  of 
different  individuals  exhibit  great  differences  in  the  stability 
of  the  vascular  equilibrium.  And  just  as  they  differ  in  their 
susceptibility  to  catarrh,  so  do  they  differ  in  their  vulnerability 
to  the  rash. 


PLATE    XII. 


The  rash  was  of  characteristic  distribution.  There  was  most  on  the  face  ;  after 
the  face,  on  the  hand  and  upper  extremity.  From  the  hand  upwards,  the 
rash  diminished  in  density.  On  the  front  part  of  the  trunk  it  was 
deficient,  especially  on  the  abdomen. 


PLATE   XIII. 

Fig.  1. — In  this  case,  according  to  rule,  the  rash  was  thicker  on  the  arms  than  on  the  back, 
and  thicker  on  the  back  than  on  the  legs.  On  the  back  the  rash  was,  relatively, 
somewhat  more  profuse  and  was  distributed  more  evenly  than  is  the  common  lot,  the 
gradation  of  density  from  above  downwards  being  very  slight.  Yet  the  gradation, 
though  slight,  was  regular,  the  incidence  being  least  between  the  shoulder-blades  and 
across  the  loins,  and  heaviest  over  the  shoulder-blades  themselves. 

Fig.  2. — 'file  back,  as  sometimes  happens,  sustained  in  this  case  a  less  abundant  emptioD 
than  the  legs.  On  the  back  the  rasli  was  of  characteristic  distribution,  diminishing 
in  density  from  the  shoulders  down  to  the  loins.  Tlie  incidence  was  characteristic- 
/     ally  increased  over  the  shoulder-blades. 


P^'cwpiipi 


PLATE    XIV. 


The  figure  shows  a  rash  most  pronounced  across  the  shoulders,  and  diminishing  somewhat  in 
intensity  from  the  spines  of  tiie  scapulae  downwards  to  the  loins.  At  *  wa.s  a  cluster 
of  spots  caused  by  the  pressure  of  a  brace-button.  About  the  middle  of  the  back 
'  the  lesions  on  either  side  of  the  spine  showed  a  tendency  to  group  themselves  along 
the  lower  ribs,  in  the  directions  marked  by  the  lines  a  a.  The  fact  appears  more 
distinctly  when  the  print  is  inverted. 


PLATE    XV. 

The  eruption  in  this  case  was  obsolescent.  The  scabs  had  fallen  from  the  upper  part  of  the 
body,  their  former  position  being  marked  out  by  pigment-splashes  on  the  surface.  The 
scabs  still  lingered  on  the  legs.  Distribution  was  characteristic.  The  rash  was  most 
dense  on  the  face  and  forearms.  On  the  upper  extremities  there  was  a  distinct 
gradation  in  density  from  the  wrists  upwards.  On  the  lower  extremities  the  gradation 
was  similar  but  less  obvious.  The  rash  was  most  scanty  on  the  front  part  of  the  trunk, 
but  was  thicker  on  the  chest  than  on  the  abdomen. 


PLATE   XVI. 

Fig.  1. — The  illustration  exhibits  the  comparative  immunity  of  the  front  part  of  the  trunk. 
Tiie  scanty  eruption  in  that  situation  was  most  pronounced  on  the  upper  part  of  the 
chest,  and  decreased  in  density  from  above  downwards.  The  rash  was  especially 
deficient  in  the  groins ;  and  those  parts  were  in  great  contrast  with  the  upper  parts 
of  the  thighs,  which  sustained  a  crop  exceptionally  profuse. 

Fig.  2, — Back  of  the  thigh  and  leg,  showing  the  relative  immunity  of  the  popliteal  space 
(a).  On  one  of  the  hamstrings  a  cluster  of  pustules  had  been  provoked  by  friction 
with  a  garter  (ft). 


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PLATE  XVIII. 

This  figure  and  Plate  xix.  are  from  the  same  case.  The  figure  illustrates  the  immunity 
ot  the  armpit,  and  the  greater  incidence  of  the  rash  on  the  outer  side  of  the  arnu 
Comparing  one  limb  with  the  other  and  one  plate  with  the  other,  it  will  be  seen  that 
Auu^^'t"^^'"  ^"""^^^^  of  *he  forearm  was  more  affected  than  the  flexor  surface. 
Although  the  rash  was  distributed  on  the  upper  extremity  much  in  the  usual  fashion 
the  case  was  exceptional  from  the  relative  immunity  of  the  hand. 


PLATJi!   XIX. 

Comparing  this  plate  with  the  last,  it  will  be  noticed  that  the  rash  had  a  greater 
incidence  over  the  deltoid  and  on  the  outer  surface  of  the  arm  than  on 
the  inner  surface.  The  figure  shows  the  rash  cliaracteristically  disposed 
upon  the  back  ;  it  illustrates  the  gradation  in  density  from  above  down-' 
wards,  and  the  exaggeration  of  the  eruption  on  the  shoulder-blade.  In 
the  groin  a  thick  crop  of  pustules  had  been  evoked  by  a  boil. 


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PLATE  XXI. 


The  rash  was  most  pronounced,  as  is  customary,  on  the  forehead  and  nose.  A  line 
(//)  has  been  drawn  from  the  ear  to  the  nose,  and  above  this  line  the  spots  lay 
thicker  than  below.  The  immunity  of  the  orbit  is  distinct,  and,  to  a  less  degree, 
that  of  the  temple  (a). 


PLATE   XXII. 


Fig.  1. 


-The  msh  was  distributed  characteristically  on  the  face  and  ear.  It  pre- 
dominated on  the  forehead  and  nose  and  cheek-bone,  and  was  sparse  in  the 
orbit  and  on  the  temple  (a).     On  the  ear  the  lesions  chose  the  edges  and 

''  convexities  of  the  shell  and  the  lobule,  and  spared  the  sub-lobular  groove 

(J).     On  the  neck  the  rash  was  more  pronounced  behind  than  in  front. 

Fig.  2.— The  illustration  shows  the  immunity  of  the  armpit,  and  of  the  flank, 
and  of  the  groove  over  the  sternum  (a). ' 


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PLATE    XXIV. 


This  case  was  exceptional  because  the  trunk  almost  entirely  escaped  the  invasion,  behind  as 
well  as  in  front.  The  normal  gradation  in  density  on  the  limbs  is  well  shown :  but, 
as  often  happens  to  children,  the  density  on  the  legs  equalled,  or  almost  equalled, 
that  on  the  arms. 


PLATE  XXV. 

The  print  illustrates  tlie  deleterious  effect  sometimes  caused  by  wearing  corsets.  The 
rash,  which  should  have  been  developed  sparsely  below  the  breasts,  was  unusually 
conspicuous  over  the  whole  area  which  the  corsets  covered.  On  the  part  of  this 
area  depicted  the  density  fell  but  little  below  that  on  the  arm.  Between  the  breasts 
will  be  ob.served  a  cluster  (J)  caused  by  the  pressure  of  the  points  of  the  corsets. 
Just  above  this  cluster  the  ra^h  was  deficient  in  the  intermammary  prroove  («). 
Near  the  armpit  the  rash  was  aggravated  by  the  chafing  of  the  under-clothing  (c). 
A  deficiency,  often  to  be  observed,  will  be  noticed  in  the  eruption  under  the  chin. 
The  case  illustrates  again  the  relative  immunity  of  the  posterior  triangle  of  the  neck. 


PLATE      XXVI. 


In  this  case  the  normal  lineal  gradation  of  density  on  the  upper  extremities 
was  reversed.  This  method  of  distribution  is  what  occurs  commonly  in 
chickenpox. 


/ 


PLATE      XXVI. 


In  this  case  the  normal  lineal  gradation  of  density  on  the  upper  extremities 
was  reversed.  This  method  of  distribution  is  what  occurs  commonly  in 
chickenpox. 


CHAPTER    IV 

DIAGNOSIS   BY   DISTRIBUTION 

The  eruption  of  smallpox  is  co-extensive  with  the  cutaneous 
circulation.  Its  lesions  may  be  developed  even  under  the 
nails.  And  there  is  no  region  which  is  peculiar  in  being  liable 
to  the  lesions  of  smallpox  but  immune  to  those  of  other 
diseases.  The  mere  fact  that  the  lesions  are  present  or  absent 
on  the  soles,  or  on  the  palms,  or  on  the  mucous  membrane  of 
the  month,  is  irrelevant  to  the  problem  of  diagnosis. 

Localised  or  elliptic  rashes. — Since  it  is  the  essence  of 
this  rash  to  be  diffused  over  the  whole  cutaneous  surface,  a 
pronounced  limitation  of  the  area  of  diffusion  is  generally 
very  cogent  evidence  that  a  ra.sh  is  not  variolous.  However 
like  the  lesions  might  be,  such  a  limitation  as  that  represented 
in  Plate  xxvii.  would  put  smallpox  out  of  count.  Even 
when  the  rash  occupies  a  greater  space,  the  distinction  may  be 
equally  easy ;  for  example,  if  its  incidence  were  limited  to  the 
face  and  arms,  or  to  the  trunk  of  the  body,  or  to  the  limbs. 
(Plate  XX VIII.)  In  other  cases  the  exclusion  will  be  influ- 
enced by  the  fact  that  the  rash,  though  widespread,  is  yet 
elliptic  in  incidence ;  as  when  scabies  attacks  all  parts  except 
the  face,  or  chickenpox  all  except  the  arms.  In  these 
examples  the  parts  to  enjoy  immunity  are  some  which  it  is 
essential  that  a  variolous  rash  should  cover.  Smallpox  would 
not  be  excluded  necessarily  if  the  abdomen,  or  even  the  whole 
trunk,  escaped ;  yet  the  cases  are  exceptional  in  which  those 
parts  are  wholly  unblemished,  and  their  complete  immunity 
would  tell  something  against  that  diagnosis. 

Generalised  rashes. — When  the  eruption  is  generalised, 
it  becomes  more  particularly  necessary  to  observe  its  order 
of  incidence.  The  vesicles  of  chickenpox  are  likely  to  be 
strewn   more   thickly   on  the   trunk   of  the  body   than   on 

21 


22  THE    DIAGNOSIS    OF    SMALLPOX 

the  face  and  limbs,  and  on  the  proximal  parts  of  the 
limbs  than  on  the  distal.  (Plate  xxix.)  An  eczematous 
rash  may  preponderate  on  the  trunk  rather  than  on  the 
face,  on  the  front  of  the  trunk  rather  than  on  the  back,  on 
the  abdomen  rather  than  on  the  chest,  or  on  the  flexor 
surfaces  of  the  limbs  rather  than  on  the  extensor.  A  large 
number  of  cases,  which  might  otherwise  prove  difficult,  may  be 
distinguished  by  such  considerations,    (Plates  xxx.  and  xxxi.) 

Supposing  even  that  there  are  none  of  these  faulty 
contrasts,  the  evidence  would  be  hardly  less  cogent  should 
the  gradation  of  density  be  inconsistent,  not  in  kind  but 
in  degree.  A  confluent  rash  on  the  face  would  be  incon- 
sistent with  a  very  scanty  rash  on  the  arms,  a  confluent 
rash  on  the  face  and  arms  with  a  relative  suppression  of 
the  rash  on  all  other  parts,  or  a  thick  rash  on  the  trunk 
with  a  very  scanty  rash  on  the  legs.  Similarly,  unless  the 
lesions  were  developed  in  insignificant  number,  their  limita- 
tion to  one  surface,  even  to  the  extensor  surface,  of  a  limb 
would  be  almost  as  inconsistent  with  smallpox  as  their 
limitation  to  one  part  of  the  body. 

The  gradation,  again,  must  be  orderly.  With  smallpox, 
an  abrupt  transition  of  density  may  occur  at  the  junction 
of  dissimilar  surfaces,  for  instance,  where  the  thigh  meets 
the  groin.  (Plates  xvi..  Fig.  1,  and  xxiv.)  But  as  a  rule, 
and  in  the  absence  of  any  obvious  disturbing  cause,  abrupt 
transitions  are  unusual.  Marked  asymmetry,  uneven  grada- 
tion over  homogeneous  areas,  or  an  irrational  patchiness  of 
distribution,  are  all  against  the  diagnosis.    (Plates  xxxii.  and 

XXVIII.) 

Laxik  of  gradation. — The  fault  may  be,  not  that  the 
gradation  is  uneven  or  abrupt,  but  that  it  is  absent.  Cases 
which  cause  sometimes  a  good  deal  of  difficulty  are  those 
in  which  a  rash,  generalised  in  distribution,  shows  no  pro- 
nounced preference  for  specific  regions.  In  a  case  of  measles, 
or  of  generalised  erythema,  it  may  be  difficult  to  say  whether 
the  rash  is  thicker  on  the  face  than  on  the  arms,  on  the 
arms  than  on  the  trunk,  on  the  trunk  than  on  the  legs ; 
because  it  is  so  equal  in  distribution  or  displays  difl'erences 


DIAGNOSIS    BY    DISTRIBUTION  23 

so  slight.  Plate  xxxiv.  is  from  a  case  in  Avhich  the  vesicular 
eruption  resembled  closely  some  that  are  seen  in  the  severer 
sorts  of  smallpox.  It  was  strewn  thickly  over  all  parts  of 
the  body,  and  the  most  obvious  difference  was  a  lack  on 
different  parts  of  a  distinct  gradation  of  density. 

A  general  lack  of  contrast  rather  than  a  faulty  contrast, 
that  is  a  kind  of  negative  evidence  upon  which  it  seems 
difficult  to  rely.  The  tendency  is  to  under-estimate  its 
value.  The  peculiarity  of  smallpox  is  that  the  differences 
of  density  spring  from  the  natural  history  of  the  disease; 
merely  the  demonstration  of  their  absence,  therefore,  is 
evidence  of  considerable  weight.  In  collecting  such  evidence 
it  is  not  enough  to  take  account  of  the  disposition  of  the 
rash  over  large  areas  and  to  estimate  its  relative  density 
on  different  parts  of  the  body,  and  on  different  parts  of  a 
limb,  and  on  opposite  surfaces  of  a  limb.  The  armpits  and 
the  groins  must  be  carefully  explored ;  the  armpit,  especially, 
is  a  mine  of  information.  (Plates  xxix.  and  xxxi.)  A  want 
of  contrast  or  a  reversed  contrast  in  those  regions  is  very 
weighty  evidence  against  smallpox.  And,  lastly,  there  are 
the  many  trifling  contrasts  of  disposition  described  in  the 
last  chapter;  these  must  be  looked  for  and  their  absence 
noted. 

This  class  of  evidence  attains  its  highest  value  when, 
in  general  outline  of  distribution,  the  variolous  eruption  is 
closely  simulated.  With  exceptional  cases  of  chickenpox 
the  mimicry  may  be  extraordinarily  close;  yet  when  the 
details  are  scrutinised  the  similarity  disappears.  Some  of 
the  most  difficult  cases  which  fall  to  be  distinguished  are 
cases  of  measles  or  of  generalised  erythema,  in  which  the 
rash  is  so  closely  mimetic  merely  because  it  is  immature. 
With  smallpox,  the  rash  begins  at  the  top  and  spreads 
downwards;  on  the  legs  efflorescence  is  often  still  in- 
complete after  the  lapse  of  forty-eight  hours.  (See  Chap.  VI., 
p.  33,  and  Plate  xlvii.)  A  similar  order  of  development 
occurs  with  mesisles,  and  may  happen  in  a  case  of  erythema. 
The  observer,  therefore,  may  be  required  to  classify  a 
papular  rash  occupying  only  the  upper  part   of  the  body, 


24  THE    DIAGNOSIS    OF    SMALLPOX 

and  for  that  reason  presenting  no  distinctive  features  in 
its  salient  lines  of  distribution.  And  what  makes  the  task 
harder  is  that  a  variolous  rash,  so  immature,  may  itself  display 
in  its  order  of  incidence  some  apparent  anomalies  which  will 
disappear  as  efflorescence  advances.  In  such  cases  as  these, 
when  the  common  rules  of  distribution  go  by  the  board,  its 
finer  details  become  our  mainstay.  If  the  rash  comes 
equally  and  indifferently  in  the  orbits  and  on  the  forehead, 
on  the  lower  part  of  the  face  and  on  the  upper,  below  and 
above  the  chin,  on  both  surfaces  of  the  ear,  on  the  lobule  and 
in  the  groove  beneath  it,  if  it  spreads  indifferently  over  the 
hollows  and  ridges  of  the  neck  and  into  the  armpit,  then 
with  some  confidence  the  further  development  of  the  case 
may  be  awaited,     (Plates  xxxiii.  and  xcv.) 

Factitious  eoMltation  of  density  in  exotic  eruptioifis. — To 
exclude  smallpox,  what  is  material  is  to  establish  the  indiffer- 
ence of  the  rash  not  only  to  exposed  but  also  to  sheltered 
places,  not  only  to  the  prominences  but  also  to  the  depressions 
of  the  surface.  It  is  not  pathognomonic  that  the  rash  picks 
out  a  ridge,  or  is  exaggerated  on  a  part  exposed  to  pressure 
or  irritation.  Of  such  facts,  a  conspicuous  or  manifold  in- 
stance, like  some  of  those  depicted  in  the  preceding  plates, 
may  clinch  the  diagnosis  which  other  evidence  suggests. 
But  it  is  important  to  remember  that  similar  phenomena  may 
be  displayed  by  other  diseases.  In  a  case  of  dermatitis  it 
would  not  be  unusual  to  find  the  pustules  clustering  where 
the  skin  had  been  subject  to  irritation.  In  a  case  of  erythema 
the  rash  is  sometimes  accented  on  a  prominence,  or  in  a  place 
exposed  to  pressure.  (Plate  xxxv..  Fig.  1.)  A  drug-rash, 
even,  such  as  that  caused  by  an  iodide  salt,  may  furnish  an 
illustration  of  the  same  order  of  fact.  And  now  and  then  a 
case  of  chickenpox  will  display  a  garter-mark  or  the  like. 
(Plate  xxxvi.,  Fig.  1.)  Yet,  in  each  instance,  in  spite  of 
the  local  idiosyncrasy  the  rash  will  preserve  a  general  indiffer- 
ence to  the  contours  of  the  surface ',  near  the  very  part,  even, 
which  has  suffered  with  peculiar  intensity  there  may  be  a 
sheltered  nook  where  the  rash,  instead  of  being  deficient,  is 
just  as  pronounced  as  on  most  of  the  neighbouring  skin. 


PLATE   XXVII. 


The  patient  had  symmetrical  pustular  dermatitis  of  the  legs,  the  lesions  of  which  bore'a 
close  resemblance  to  the  pustules  of  smallpox.  The  only  other  lesions  present  were  a 
few  impetiginous  spots  on  the  chin. 


PLATE  XXVIII. 


The  patient  had  an  attack  of  acute  pustular  eczema,  the  incidence  of  the  rash  being  limited 
to  the  face,  neck,  shoulders  and  arnns.  The  gradation  of  density  on  the  arms  was 
the  reverse  of  that  commonly  encountered  in  cases  of  smallpox.  The  eruption, 
besides,  was  too  patchy  in  its  incidence. 


N 


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i 


PLATE   XXIX. 


In  this  case  of  cbickenpox  the  rash  was  most  abundant  on  the  trnnk,  and  on  the  face  it  was 
more  scjanty  than  on  the  cliest.  The  lineal  gradation  of  density  on  the  arms  was 
what  is  frequent  with  chickenpox,  unusual  with  smallpox.  The  gradation  on  the 
trunk  was  such  as  is  usual  with  smallpox,  but  the  distribution  was  too  random  in 
detail.  It  will  be  noticed,  particularly,  that  the  ra->ih  showed  a  complete  indifference 
to  the  armpit. 


PLATE   XXX. 


In  this  case  the  patient  was  attacked  with  generalised  erythema,  and  some  of  the 
lesions  on  the  arms  became  vesicular.  The  rash  was  concentrated  on  the 
limbs  and  was  meagre  on  the  face.  The  trunk  also  was  attacked ;  but  it 
will  be  observed  that  the  incidence  was  on  the  lower  part  of  the  trunk 
rather  than  on  the  upper  part. 


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Fig.  1.— The  affection  in  this  case  was  acute  urticiria.  The  rash  was  disposed  on  the  hand 
not  unlike  a  variolous  eruption.  It  was  accented  over  the  knuckles  and  over  the 
head  of  the  radius. 

Fig.  2. — This  figure  makes  a  companion  picture  to  Fig.  2  of  the  next  plate.  This  was 
smallpox,  that  chickenpox.  In  each  case  the  rash  was  exceedingly  meagre ;  but  the 
evidence  from  distribution  was  of  value.  In  this  instance  the  few  .»ipots  which  were 
developed  came  on  the  face  and  limbs,  situations  favoured  by  smallpox ;  in  the  other, 
with  the  exception  of  three  spots  which  came  on  the  face,  all  were  on  the  trunk  and 
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DIAGNOSIS    BY    DISTRIBUTION  25 

Meagre  eruptions. — When  the  rash  is  scanty  these  in- 
differences of  distribution  are  more  difficult  to  estabhsh.  The 
hardest  problems  arise  when  the  rash  is  both  scanty  and 
widespread,  for  only  the  broader  features  of  distribution  can 
then  be  taken  account  of,  and  they  may  happen  to  be  uncon- 
vincing. In  such  cases,  to  map  out  the  spots  on  a  chart  helps 
in  deciding  how  lies  the  balance  of  evidence.  Should  the 
lesions  be  very  few  in  number,  it  may  be  that  no  valid 
evidence  against  smallpox  would  lie  even  in  a  limitation  of 
their  area  of  diffusion  ;  but  for  such  evidence  to  be  invalid 
they  must  be  so  few  that  they  may  be  counted  in  a  figure 
approaching  a  single  number.  And  it  will  be  still  true  that, 
if  they  are  variolous,  they  will  be  most  apt  to  come  on  those 
parts  which  suffer  most  when  the  rash  is  in  plenty.  They 
should  be  found  on  the  upper  part  of  the  body ;  though  there 
may  be  no  more  than  a  dozen  spots,  the  evidence  would  be 
against  smallpox  if  none  were  found  upon  the  face.  (Plates 
XXXV.,  Fig.  2,  and  xxxvi.,  Fig.  2.) 

The  faith  must  never  be  pinned  to  one  part  of  the 
evidence  only.  There  are  exceptions  to  all  the  rules,  and 
it  is  not  always  that  the  disturbing  cause  can  be  detected. 
A  patient  may  still  have  smallpox  though  the  rash  come  on 
the  arm  more  than  on  the  forearm,  or  on  the  ffexor  surface 
of  a  limb  more  than  on  the  extensor  surface,  or  on  the 
abdomen  more  than  on  the  chest,  or  even  though  the  groins 
be  filled.  {See  Chapter  X.,  p.  69.)  Yet  all  the  exceptions  will 
not  occur  in  the  same  case,  and  if  there  is  no  dearth  of 
evidence  and  all  of  it  is  weighed  there  will  be  little  risk  of  a 
faulty  judgment. 


CHAPTER    V 

THE    LESION 

Life-history. — Counting  to  the  time  of  incrustration,  the 
evokition  of  the  lesion  in  a  case  of  natural  smallpox  occupies 
about  eight  days.  The  exact  duration  of  the  period  depends 
upon  the  character  of  the  lesion  and  upon  the  nature  of  the 
case.  Some  of  the  lesions  of  modified  smallpox  huiTy  through 
their  life  in  three  or  four  days,  while  in  the  severest  cases  of 
confluent  smallpox  even  the  normal  period  may  be  prolonged. 
In  the  evolution  of  a  typical  lesion  the  time  occupied  by  the 
several  stages  is  about  two  days  for  the  papule,  two  for  the 
vesicle,  and  four  more  until  the  pustule  begins  to  incrust. 
Relatively  to  the  other,  the  duration  of  the  papular  or  of  the 
vesicular  stage  is  inconstant.  A  day  may  be  taken  from  the 
first  and  added  to  the  second,  four  days  still  measuring  their 
combined  duration. 

At  its  birth  the  spot  is  very  small,  about  as  big  as  a 
pin's  head.  (Plates  xxxvii.,  xxxviii.,  and  xxxix.)  It  is  just 
a  fleck  in  the  skin,  flush  with  the  surface  and  imperceptible 
to  the  touch.  In  a  few  hours  it  swells  up  into  a  raised, 
hard,  solid-feeling,  pink  mass,  the  papule.  In  the  course  of  a 
day  or  two  the  small  round-topped  papule  begins  to  get 
vacuolated  at  the  top.  This  change  spreads  throughout  the 
lesion,  which  at  the  same  time  gets  bigger  and  by  the  fourth 
day  of  its  life  has  become  grey  and  translucent.  The 
smaller  vesicles  are  generally  hemispherical,  the  larger  flat- 
topped,  and  the  crown  of  the  vesicle  is  sometimes  indented. 
At  this  stage,  if  it  is  pricked  or  incised,  the  fluid  contents 
are  not  wholly  emptied ;  the  cavity  is  loculated.  The  vesicle 
remains  clear  for  about  twenty-four  hours  only ;  its  covering 
then  becomes  dull  and  whitish,  and,  followmg  this  change, 
its  contents  become   turbid.     This   metamorphosis   into   the 

28 


THE    LESION  27 

pustule  is  a  gradual  process  and,  if  the  lesion  be  not  too 
small,  can  be  plainly  detected  to  begin  at  the  periphery  and 
to  proceed  towards  the  centre.  In  the  intermediate  state 
between  the  vesicle  and  the  pustule,  a  white  or  yellow  ring 
at  the  periphery  of  the  crown  encircles,  iris-like,  the  grey 
translucent  centre,  imparting  to  the  lesion  a  characteristic 
ringed  appearance.  (Plate  xliv.)  By  the  sixth  day  the 
lesion  has  turned  yellow  throughout  and  contains  thin  pus; 
the  crown  has  become  dome-shaped  and  the  pustule  has 
arrived  at  maturity. 

Size. — From  its  birth  to  its  maturity  the  lesion  grows  as 
it  ages.  The  largest  papule  is  no  bigger  than  the  head  of 
a  bee  ;  the  largest  vesicle  may  reach  the  size  of  the  top  of  a 
cedar  pencil ;  and  a  full-sized  pustule  is  about  three-eighths 
of  an  inch  across.  But  many  of  the  lesions  do  not  attain 
these  dimensions  even  in  cases  of  natural  smallpox. 

The  areola. — These  statements  of  size  take  no  account  of 
the  areola.  (Plates  xl.,  xli.,  xlii.,  and  xliii.)  This  is  seen 
first  during  the  papular  stage.  As  the  papule  gains  in 
prominence  it  becomes  encircled  by  a  narrow  erythematous 
zone,  which  gets  broader  with  the  change  into  the  vesicle. 
The  areola  is  biggest  and  brightest  at  the  height  of  the 
vesicular  stage  and  begins  .to  wane  with  the  onset  of  sup- 
puration ;  the  pustule,  when  mature,  has  no  areola.  The 
colour  is  light  red  and,  under  ordinary]  conditions,  is  dis- 
charged readily  by  pressure.  The  breadth  of  the  zone  is 
very  variable.  It  seems  to  be  determined  by  the  intensity 
of  the  inflammatory  reaction  of  the  skin  rather  than  by 
the  virulence  of  the  destructive  process.  A  broad  areola, 
therefore,  is  a  good  sign  rather  than  otherwise.  The  biggest 
are  seen  in  some  cases  of  modified  smallpox,  encircling 
diminutive  vesicles.  In  such  cases  the  area  covered  may 
be  as  big  as  a  shilling,  and  the  small  vesicles  so  surrounded 
look  ver}'  like  those  met  with  in  some  cases  of  chickenpox. 

Involution. — About  the  ninth  day  of  efllorescence  the 
crust  begins  to  form.  In  ordinary  circumstances  the  whole 
lesion  undergoes  inspissation  and,  in  the  course  of  a  few  days, 
a  solid  brown  disc-shaped  scab  is  left  embedded  in  the  skin. 


28  THE    DIAGNOSIS    OF    SMALLPOX 

(Plate  XLV.,  Fig.  1.)  This  falls  off,  in  cases  of  unmodified 
smallpox,  about  the  fourteenth  day  of  efflorescence.  The  con- 
dition left  after  the  fall  of  the  scab  will  be  referred  to  in 
Chapter  VIIL 

Critical  signs. — The  characteristics  held  traditionally  to 
be  distinctive  of  variolous  lesions  are  the  loculation  of  the 
cavity  of  the  vesicle,  its  umbilication,  and  the  soliditj'  and 
hardness  of  the  papule.  As  reliable  guides  in  diagnosis 
these  signs  must  be  accepted  with  some  qualification.  It  is 
obvious  that  the  tests  with  which  they  furnish  us  can  be 
applied  only  during  a  certain  part  of  the  illness.  And,  in 
general,  though  the  demonstration  of  the  signs  may  be  good 
evidence  in  favour  of  smallpox,  failure  to  demonstrate  them 
does  not  necessarily  teU  against  that  diagnosis.  Their 
meaning  and  the  limits  of  their  usefulness  will  be  better 
understood  by  reference  to  the  histology  of  the  lesion. 

The  frontispiece  represents  a  section  of  a  portion  of  a 
variolous  lesion  in  which  vacuolation  was  beginning.  The 
lesion  occupied  the  whole  depth  of  the  epidermis,  had  the 
deeper  layers  for  its  floor,  and  was  roofed  by  the  cuticle. 
At  the  centre  the  floor  was  thin,  and  by  the  further  growth 
of  the  lesion  even  the  deep  la3'er  of  cylindrical  cells  would 
have  been  worn  away  and  the  corium  invaded  It  is  owing 
to  this  erosion  of  the  regenerative  cells  that  smallpox  leaves 
scars.  Yet,  though  the  corium  sufi:ers,  it  is  its  upper  fringe 
only,  the  papillary  layer,  which  is  commonly  involved  in  the 
area  of  destruction.  The  inflammation  crowds  within  sharp 
limits  and  does  not  encroach  sensibly  upon  the  true  skin. 

Loculation. — When  fluid  is  effused  rapidly  into  a  solid 
tissue,  the  tissue  splits,  and  splits  along  the  line  of  least 
resistance.  With  chickenpox  the  focus  of  activity  is  just 
below  the  surface,  and  nothing  confines  the  flow  of  serum 
but  the  overlying  sheet  of  horny  epidermis.  This  the  fluid 
strips  up,  the  natural  plane  of  cleavage  lying  parallel  to  the 
cutaneous  surface.  But  with  smallpox  the  effusion  takes 
place  more  deeply  among  the  epidermal  cells,  where  there 
are  no  natural  lines  of  parting.  The  columns  of  cells  are 
forced  apart  irregularly  and  the  fissures,  for  the  most  part, 


THE    LESION  29 

are  perpendicular  to  the  surface.  (See  Frontispiece.)  This 
irregular  splitting  of  the  epithelial  cells  has  the  effect  of 
dividing  the  vesicle  into  many  compartments.  With  the 
onset  of  suppuration  the  walls  which  separate  the  compart- 
ments break  down  ;  the  pustule  is  not  loculated. 

That  the  cavity  is  loculated,  is  determined  by  piercing 
the  vesicle  and  observing  that  all  the  fluid  contents  cannot 
be  emptied  through  the  wound.  There  are  many  cases  of 
smallpox  in  which  this  test  can  be  applied  satisfactorily, 
and  many  cases  of  chickenpox  in  which,  with  equal  readiness, 
the  vesicles  can  be  shown  to  be  unilocular.  Nevertheless, 
the  practical  value  of  the  test  is  inconsiderable ;  for  the 
cases  in  which  the  reaction  is  unambiguous  are  those  which 
can  be  distinguished  even  more  readily  by  other  means. 
When  the  vesicles  are  small  or  flaccid,  as  may  happen  in 
cases  of  either  disease,  it  is  so  difficult  to  judge  of  the 
completeness  of  the  evacuation  of  the  fluid  that  it  is  easy 
to  form  an  umvarranted  opinion.  Moreover,  there  are  cases 
in  which  the  reaction  to  the  test  would  really  warrant  a 
wrong  conclusion.  Vesicles  are  sometimes  loculated  in  cases 
of  chickenpox,  though  perhaps  imperfectly  loculated.  On 
the  other  hand,  unilocular  vesicles  may  be  observed  not 
infrequently  in  cases  of  smallpox.  The  circumstances  pro- 
ductive of  these  ambiguities  will  be  discussed  presently. 

The  tactile  imipression  of  the  papule. — The  solidity  ot 
the  papule  is  wholly  spurious.  The  effect  is  produced  by  the 
effusion  of  fluid  under  pressure.  The  vesicle  of  chickenpox  is 
caused  by  an  inflammatory  reaction  equally  acute ;  but  with 
that  disease  there  is  ordinarily  no  precedent  papule  because 
the  pressure  of  the  fluid  effused  is  at  once  relieved  by  the 
separation  of  the  cuticle,  bound  do\vn  so  lightly  to  the  parts 
below.  With  smallpox  the  focus  of  inflammation  lies  deeper ; 
and  the  expansion  of  the  fluid  is  restrained  by  the  compact- 
ness of  the  tissue  into  which  it  is  effused.  To  separate  the 
cells  the  fluid  must  gain  a  high  degree  of  tension ;  and  some 
two  days  go  by  before  it  gathers  force  enough  so  to  tear  the 
tissue  that  signs  of  vacuolation  are  perceptible  to  the  eye. 
Nevertheless,  the  vacuoles  are   there  long  before   they  are 


30  THE    DIAGNOSIS    OF    SMALLPOX 

evident  and  the  papule  derives  its  firmness  from  the  tension 
of  the  fluid  which  fills  them. 

When  the  circumstances  are  most  favourable,  the  sign  is 
very  characteristic.  The  limits  of  the  papule  are  remarkably 
distinct.  It  projects  but  little  above  the  surface  and  feels  like 
a  hard,  round,  foreign  body  embedded  in  the  epidermis. 
These  qualities,  being  attributable  to  the  effusion  of  serum 
into  a  compact  tissue,  are  best  perceived  on  the  face,  where, 
the  blood-supply  being  most  abundant,  the  effusion  is  most 
rapid.  Moreover,  the  frontal  bone  makes  a  convenient  back- 
ground for  manipulation.  The  hand  and  forearm  are  also 
situations  favourable  to  the  sign.  On  the  soft  parts,  and  in 
those  situations  where  the  skin  is  soft  and  flaccid,  the 
peculiar  qualities  of  the  papule  may  be  lost  even  in  un- 
exceptional cases ;  and  there  are  exceptional  circumstances 
in  which  they  may  be  wholly  lacking  even  upon  the  face. 

Aberrant  cases. — There  are  two  essential  factors  which 
contribute  to  those  distinctive  characteristics  of  the  papule 
and  the  vesicle  which  have  just  been  described.  One  is 
the  acuteness  of  the  inflammatory  process,  the  other  is  the 
position  of  the  lesion  among  the  deeper  strata  of  the  epithe- 
lial cells.  In  cases  of  different  kinds,  one  or  other  of  these 
factors  may  be  wanting.  From  any  cause  which  subdues  the 
intensity  of  the  inflammation,  or  in  any  case  in  which  the 
lesions  are  abnormally  superficial,  the  papules  may  be  soft, 
and  the  vesicles  may  be  either  imperfectly  loculated  or  so 
deficient  in  serous  contents  that  the  loculation  is  imperfectly 
perceived.  For  the  first  reason  these  tests  may  fail,  especially 
if  the  skin  is  thin  and  flabby,  when  the  subjects  are  of  feeble 
vitality  and  of  weak  circulation,  as  in  the  cases  of  the  very 
young  or  the  very  old.  For  the  same  reason  they  may  fail  in 
certain  of  the  more  serious  forms  of  smallpox  in  which  the 
circulation  is  apt  to  be  defective,  as  will  be  related  in  the  next 
chapter.  And  for  the  second  reason  the  tests  may  fail  in 
cases  of  highly  modified  smallpox  which  are  liable  to  be 
signalised  by  particularly  small  and  superficial  lesions.  It 
must  be  remembered,  also,  that  whatever  the  severity  of  the 
attack  and  however  resistant  the  papule  may  be  destined  to 


THE    LESION  31 

become  in  its  maturity,  yet  at  the  time  of  its  outcrop,  before 
the  requisite  tension  has  been  attained  in  the  fluid  effused,  it 
may  be  altogether  wanting  in  firmness. 

Position. — Since  these  signs  depend  upon  the  precise 
depth  of  situation  of  the  lesion,  it  is  obvious  that  if  that  situa- 
tion can  be  gauged  its  determination  will  furnish  us  with  yet 
another  test.  The  skin  of  the  trunk  and  limbs  is  easier  to 
manipulate  than  the  thick  skin  of  the  face.  The  tissue  should 
be  nipped  up  and  rolled  lightly  between  the  finger  and  thumb. 
The  lesion  should  be  well  defined ;  and  it  is  generally  possible 
to  estimate  whether  it  bulks  too  largely  in  the  deeper  layers 
of  the  skin,  like  an  acne-spot,  or  is  a  mere  excrescence  on  the 
surface  like  a  chickenpox-vesicle,  or  really  lies  embedded  in 
the  epidermis. 

Often  the  evidence  appeals  to  the  eye  even  better  than 
to  the  touch.  The  lesion  of  smallpox  juts  through  the  skin 
and  lifts  the  horny  epidermis  at  an  angle.  (Plate  xliv.) 
Lesions  like  acne-pustules  or  deep-seated  syphilides,  rooted 
in  the  deeper  part  of  the  corium,  have  a  greater  thickness 
of  skin  to  push  before  them  and  bulge  up  from  below  with 
a  more  gradual  slope.  (Plate  cxviii.)  On  the  other  hand, 
superficial  vesicles,  such  as  those  of  chickenpox,  appear  to  lie 
on  the  surface  of  the  skin  rather  than  within  it.  Though 
the  vesicle  of  smallpox  has  a  steep  gradient  of  slope,  it  joins 
the  flat  skin-surface  with  a  rounded  angle.  But  the  vesicles 
of  chickenpox,  when  the  wall  is  thin  enough,  spring  abruptly 
from  the  surface  like  bubbles  on  soapy  water. 

If  the  lesion  is  found  to  inhabit  the  middle  part  of  the 
skin,  that  fact  does  not  necessarily  exclude  an  exotic  origin. 
A  syphilitic  pustule  may  have  a  situation  and  a  character 
indistinguishable  from  those  of  a  variolous  pustule.  Yet,  if 
most  of  the  pustules  were  found  to  be  so  situated,  another 
cause  than  smallpox  would  be  improbable  unless  the  eruption 
were  sparse.  The  same  sort  of  remark  is  true  of  papular 
lesions,  not  because  it  is  uncommon  for  the  papular  lesions 
of  other  diseases  to  be  situated  in  the  middle  region, 
but  because  they  are  seldom  so  weU  defined  that  their  depth 
of  situation  can  be  gauged.     On  the  other  hand,  smallpox  is 


32  THE    DIAGNOSIS    OF    SMALLPOX 

not  necessarily  to  be  excluded  because  the  lesion  is  superficial 
or  because  it  is  too  soft  for  profitable  manipulation.  There 
are  exceptional  cases  in  which  the  same  circumstances  must 
be  allowed  for  as  were  seen  to  operate  in  tempering  the 
hardness  of  the  papule. 

The  two  tests,  that  furnished  by  the  tactile  impression  of 
the  papule  and  that  afforded  by  estimating  the  position  of  the 
lesion,  are  supplementary  the  one  to  the  other  and  are  the 
most  useful  guides  in  determining  the  nature  of  individual 
variolous  lesions.  Yet  this  test  has  the  advantage  over  the 
other,  that  it  is  capable  of  wider  appUcation.  It  can  be 
applied  in  all  stages  of  evolution  of  the  lesion  and  can  be  used  in 
many  cases  in  which  the  papule,  though  of  ambiguous  consist- 
ence, is  still  sufficiently  distinct  for  its  position  to  be  ascertained. 

Uinhilicatioii. — By  the  term  "umbilication"  is  understood 
a  saucer-shaped  depression  in  a  distended  vesicle,  or  a  mere 
indentation  of  its  surface,  or  even  a  pin-point  dimpling. 
(Plates  XL VI.,  XXXVIII.,  Fig.  2,  and  xl.)  True  umbilication  is 
peculiar  to  the  vesicle.  Pustules  which  have  a  flattened  or 
a  concave  surface  are  encountered  not  infrequently  in  cases 
of  smallpox  as  well  as  with  other  diseases.  (Plate  xlv.,  Fig. 
2.)  This  effect  is  caused  by  the  absorption  of  the  fluid  con- 
tents of  the  pustule,  and  by  the  consequent  sagging  of  its  crown. 
Vesicles,  even,  if  they  are  flaccid  may  display  a  spurious 
umbilication  of  precisely  similar  character  and  causation. 

A  spurious  umbilication  of  the  vesicles  is  seen,  not  infre- 
quently, in  cases  of  chickenpox.  But  with  that  disease  a  real 
dimpling  of  the  vesicle  is  sometimes  met  with.  Such  a 
dimpling  is  caused,  generally,  by  the  crown  of  the  vesicle 
being  tethered  by  the  unruptured  neck  of  a  hair-follicle  or  a 
sweat-gland.  Seldom  more  than  a  few  vesicles  are  so  affected, 
but  in  rare  cases  the  phenomenon  is  more  conspicuous. 

Whatever  the  fundamental  cause  may  be,  the  vesicular  in- 
dentation of  smallpox,  like  the  other  signs  which  have  been 
discussed,  depends  upon  the  position  of  the  lesion  in  the  skin. 
Inconstant  always,  it  is  absent  in  the  majority  of  cases  of 
modified  smallpox  and  invariably  in  the  more  aberrant  forms 
of  it.     The  sign,  therefore,  is  of  little  value  in  diagnosis. 


PLATE  XXXVII. 

In  Plates  xxxvii.  and  xxxviii.  a  series  of  four  illastrations  represents  the  same  hand 
bearing  an  eruption,  wholly  unmodified,  in  different  stages  of  evolution.  In  this  plate 
the  rash  is  depicted  in  tlie  papular  stage.  The  outcrop  was  gradual,  not  half  of  the 
lesions  having  yet  appeared  when  the  first  photograph  was  taken.  Fig.  2  was  from  a 
pliotograph  taken  twenty-four  hours  later,  and  shows  the  papular  eruption  disclosed 
almost  in  its  full  numerical  severity.  Many  of  the  lesions  represented  in  each  figure 
y?ere  in  the  prepapnlar  stage,  and  consisted  of  red  flecks  in  the  skin,  flush  with  the 
surface.  A  comparison  of  the  two  figures  will  show  the  growth  of  the  lesions  in  size 
as  well  as  in  numbers,  some  of  the  older  papules  represented  in  Fig.  2  having  attained 
a  considerable  size. 


PLATE    XXXVIII. 

The  eruption  figured  in  Plate  xxxvil.  is  here  represented  in  the  vesicular 
stage.  The  interval  which  elapsed  between  the  states  represented  in 
Figs.  1  and  2  of  this  plate,  as  of  the  last,  was  twenty-four  hours ;  but 
the  photographic  original  of  Fig.  1,  Plate  xxxvill.,  was  taken  forty- 
eight  hours  later  than  that  of  Fig.  2,  Plate  xxxvii.  The  series,  there- 
fore, represents  an  eruption  on  the  first,  second,  fourth,  and  fifth  days  of 
efflorescence.  Fig.  1  depicts  the  eruption  at  a  time  when  the  vesicular 
change  had  not  far  advanced.  Many  of  the  lesions  were  still  in  the 
papular  stage.  Comparing  this  print  with  Fig.  2,  Plate  xxxvil. ,  it  will 
be  noticed  that  in  the  interval  of  two  days  the  lesions  had  materially 
increased  in  size  and  that  a  few  of  the  vesicles  had  become  umbilicated. 
In  the  state  represented  in  Fig.  2,  Plate  xxxvill.,  the  vesicular  change 
was  at  its  height  and  a  few  of  the  lesions  displayed  signs  of  impend- 
ing suppuration.  The  vesicles  had  increased  still  further  in  size  and 
had  become  confluent.  Many  of  the  vesicles  were  umbilicated.  The 
majoritj,  though  not  umbilicated,  were  fiat-topped. 


PLATE  XXXVIII. 


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CHAPTER  VI 

THE  ERUPTION  AND  THE  ERUPTIVE  FEVER 

Alike  in  its  outcrop  and  in  its  subsequent  evolution,  the 
eruption  maintains  a  certain  order  of  precedence. .  The  first 
papule  may  come  on  the  face,  or  on  the  wrist,  or  perhaps  on 
the  trunk  of  the  body.  Yet,  in  broad  terms,  the  rash  begins 
at  the  top  and  travels  downwards,  and  invades  the  legs  some 
twenty-four  hours  after  its  first  appearance  higher  up.  The 
lead  so  secured  by  the  lesions  on  the  face  is  maintained  in 
their  further  development. 

In  the  milder  sorts  of  cases  the  whole  rash  may  be  out 
within  twenty-four  hours  from  the  birth  of  the  first  papules. 
On  the  other  hand,  in  severe  cases  even  the  lapse  of  forty- 
eight  houi*s  may  hardly  see  the  last  arrivals.  That  is  to  say, 
the  outcrop  is  a  gradual  process  not  only  over  the  whole  body 
but  also  on  any  one  particular  part.  The  papules  first  to 
come  on  the  face  are  not  only  twenty-four  hours  in  advance 
of  those  on  the  legs,  but  are  also  twenty-four  hours  in  advance 
of  the  laggards  on  the  face  itself.  Under  such  circumstances, 
the  patient  may  exhibit  on  the  first  day  of  efflorescence  a 
scanty  rash  on  the  face  and  upper  part  of  the  body  only,  on 
the  second  day  a  profuse  rash  on  the  face  and  a  scanty  rash 
on  the  legs,  and  not  until  the  third  day  a  rash  of  normal 
proportions  in  its  incidence.  (Plates  xlvii.  and  xciv.)  As 
mentioned  in  Chapter  IV.,  this  consideration  must  not  be 
lost  sight  of  in  determining  the  distribution  of  a  papular 
eruption. 

Confluent  smallpox. — During  the  outcrop  the  toxaemia 
fever  culminates.  Between  that  time  and  the  time  of 
maturation  there  is,  in  a  case  of  confluent  smallpox,  a  striking 
metamorphosis  of  the  patient.  (Plates  XLViii.  and  xlix.)  At 
first  he  wears  his  normal  aspect,  altered  only  by  the  operation 

D  33 


34 


THE    DIAGNOSIS    OF    SMALLPOX 


of  the  poison  that  is  working  in  him.  The  papules  of  small- 
pox seldom  itch  much  or  cause  appreciable  discomfort,  and 
in  their  size  and  appearance  they  bear  no  promise  of  the 
events  which   are  in   train.      The  rash,   therefore,  like   the 


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Chart  ii. — Discrete  Smallpox  with  SE^•ERE  Suppurative  Fever. 
No  Pre-euuptive  Fever. 


rash  of  measles,  causes  no  syiijptoms  and  but  little  dis- 
figurement; as  yet  it  is  itself  but  a  symptom.  If  the 
transition  were  not  seen,  the  subject  of  the  early  illness 
would  not  presently  be  recognised  In  the  period  of  suppu- 
ration the  rash,  which  was  once  a  symptom,  has  become  the 
disease.     It  clogs  the  features,  hampers  the  movements,  and 


THE  ERUPTION  AND  THE  ERUPTIVE  FEVER    35 

enfolds  the  patient  like  a  parasite.  The  difference  in  the 
symptoms  and  the  aspect  agrees  with  the  double  sweep  of 
the  temperature  curve,  and  it  is  where  the  curve  breaks  that 
the  character  of  the  symptoms  changes.     {See  Chart  i.,  p.  4.) 


106° 
105" 
104° 
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CiiAiiT  III. — Confluent  Smallpox  with  Moderate  Suppurative  Fever. 


Evolution. — From  the  first  state  the  patient  passes  by 
easy  stages  in  which,  bit  by  bit,  the  fever  loosens  its  hold, 
while  the  rash  gains  more  in  prominence  and  begins  to  assert 
its  domination,    (Plates  L.,  li.,  and   lii.)    Tjbe  lesions  grow 


36  THE    DIAGNOSIS    OF    SMALLPOX 

and  about  tlie  fifth  day  of  efflorescence,  when  the  patient 
feels  at  his  best  and  may  even  have  a  normal  temperature, 
his  face  and  body  are  covered  with  large  flat  vesicles. 
Already  the  skin  has  begun  to  swell  and  feels  stiff'.  The  face 
looks  as  if  covered  with  a  grey  caul,  tight-fitting,  with  a 
broken  surface,  which  partly  hides  but  does  not  yet  obscure 
the  shape  and  play  of  features.  The  patient  has  freed  him- 
self from  the  symptoms  of  his  first  illness,  but  has  not 
begun  to  taste  the  poison  of  the  second,  or  yet  to  realise 
the  obsession  of  the  rash  which  will  engender  it. 

It  is  variable  to  what  extent  the  temperature  falls  in  the 
stage  of  vesiculation,  and  on  what  day  it  is  lowest.  Most 
often,  the  lowest  point  on  the  curve  is  reached  on  the  fifth 
day  of  efflorescence ;  but,  nearly  as  frequently,  on  the  sixth 
day  or  the  fourth.  (Charts  i.,  ii.,  and  iii.)  Commonly, 
even  in  cases  of  confluent  smallpox,  at  this  dip  in  the  curve 
the  thermometer  does  not  register  more  than  99*^.  But  in 
some  of  the  severer  cases  the  recession  is  not  so  evident, 
and  the  temperature  does  not  fall  below  101®  or  102®. 
With  the  progress  of  suppuration  the  curve  of  temperature 
again  ascends  and  attains  its  acme  on  the  ninth  or  tenth  day 
of  efflorescence  or,  it  may  be,  earlier  or  later  according  to  the 
severity  of  the  case. 

Maturation. — In  most  cases  suppuration  begins  on  the 
face  on  the  fifth  day  of  efflorescence,  but  is  not  fully  developed 
there  until  the  sixth.  And  it  is  not  until  nearer  the  eighth 
that  the  rash  attains  its  maturity  over  the  whole  body.  At 
that  time  a  patient  Avith  severe  confluent  smallpox  presents  a 
very  striking  picture.  (Plates  xlix.,  lii.,  Fig.  1,  Liii.,  and  Liv., 
Fig.  1.)  The  natural  features  are  obliterated,  partly  by  the 
rank  growth  of  pustules,  partly  by  the  swelHng  of  the  skin 
below  them.  The  face  is  bigger  and  broader,  and  the  patient 
looks  unnaturally  aged.  His  orbits  swell  up,  and  the  eyelids, 
and  he  peers  out  through  the  slits  between  them.  The  nose 
is  thick  and  squat,  like  a  bottle-nose ;  the  lips  are  like  a 
negro's,  but  immobile,  dough-like.  The  cheeks  are  puffed  out, 
and  the  ears  are  thickened.  The  play  of  features  is  paralysed 
by  the  mass  which  clogs  their   movements.     The   patient 


THE  ERUPTION  AND  THE  ERUPTIVE  FEVER    37 

mumbles  when  he  speaks,  and  his  voice  is  hoarse  or  whispering 
from  the  swelling  of  his  larynx.  The  hands  are  swollen,  and 
he  moves  his  fingers  like  pegs. 

To  this  loathsome,  all-pervading  rash  the  patient's  fever 


106* 
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Chart  iv. — Severe  Discrete  Ssjallpox  with  Moderate  Secondary  Fea-br. 


and  all  his  symptoms  are  due.  The  secondary  fever  is 
purely  a  suppurative  fever,  caused  by  the  absorption  of 
septic  products  from  the  pustules,  and  proportional  to  the 
amount  of  that  absorption.  Partly  because  the  rash  is  most 
in  plenty  on  the  face,  and  partly  on  account  of  its  greater 
vascularity,  it  is  from  the  face  that  the  absorption  is  greatest 


38 


THE    DIAGNOSIS    OF    SMALLPOX 


It  is  an  observation  of  Sydenham,  as  true  as  it  is  old,  that 
the  patient's  fever  and  his  prospects  of  recovery  are  measured 
by  the  amount  of  suppuration  which  the  face  sustains. 

The  sweep  of  the  curve  of  temperature  of  the  secondary 


106* 

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ChABT    v. — CoXFLrENT   SSCALLPQ-S   IIODIFIED.       SeVEKE    ToX.tlMIC    FeTEK 
WITH    A    PCKPURIC   EaSH. 


fever  is  not  so  bold  as  of  the  primary.  In  the  worst  cases  the 
temperature  may  exceed  105^.  Yet  in  most  cases  of  severity, 
including  many  fatal  cases,  it  does  not  much  exceed  103^  ;  and 
in  the  great  bulk  of  milder  cases,  whether  the  rash  is  discrete 
or  confluent,  it  does  not  attain  that  Ihnit.   Smallpox  in  its  sup- 


THE  ERUPTION  AND  THE  ERUPTIVE  FEVER   39 

purative  stage  is  not,  in  fact,  a  highly  febrile  disorder ;  and  the 
skin  may  suffer  much  disturbance  and  cause  but  a  trifling 
pyrexia.  With  the  milder  sorts  of  discrete  smallpox,  febrile 
symptoms  are  hardly  to  be  looked  for  ;  and  with  confluent 
smallpox,  if  the  suppurative  process  is  incomplete,  as  it  is  so 
often  among  vaccinated  persons,  the  fever  may  be  almost  as 
insignificant.    (Charts  iv.  and  v.) 

Involution  and  termination. — From  about  the  ninth  day 
of  efilorescence,  in  the  more  favourable  cases,  the  pustules 
dry  up  and  scab  over  and,  following  this  involution  of  the 
rash,  defervescence  sets  in  quickly.  (Plate  liv.,  Fig.  2.)  In 
the  more  serious  cases  pus,  stained  brown  by  altered  blood, 
collects  below  the  crusts  formed  on  the  surface  and  may 
exude  from  the  broken  pustules,  (Plate  Lii.,  Fig.  2.)  In  the 
latter  cases  this  period  is  the  most  critical ;  for  the  absorption 
of  septic  matter  continues,  the  temperature  remains  high, 
and  there  is  apt  to  be  delirium  which  is  often  violent.  In 
some  of  the  worst  cases  of  all,  before  there  is  time  for  incrus- 
tation to  occur,  there  is  extensive  shedding  of  the  cuticle.  In 
these  cases  the  rash  is  unusually  profuse  and  the  denuded 
parts,  it  may  be  the  face,  or  the  limbs,  or  the  back,  are  such  as 
are  covered  by  a  confluent  eruption.  Raw,  weeping  surfaces 
are  thereby  left  exposed,  and  the  cases  are  nearly  always 
fatal.  When  death  occurs  during  the  suppurative  fever  the 
fatal  day  is,  generally,  between  the  eleventh  and  fifteenth  of 
efilorescence.  The  fatal  result  is  due,  as  a  nde,  either  to 
septic  absorption  or  to  broncho-pneumonia  set  up  by  the 
affection  of  the  air-passages. 

Discrete  smallpox. — Cases  depart  from  the  type  which 
has  been  described  in  being  either  less  or  more  serioua 
With  confluent  smallpox  of  the  milder  sorts,  and  with 
discrete  smallpox,  the  domination  of  the  rash  is  less  pro- 
nounced and  less  sustained.  (Plate  lv..  Figs.  1  and  2.)  Dis- 
crete smallpox,  unless  by  accident  and  except  in  infants,  is 
not  a  fatal  disease,  and  in  cases  of  no  more  than  moderate 
severity  the  secondary  symptoms  are  insignificant  (Chart  iv. 
and  Chart  vii.,  p.  64)  This  is  true  of  the  vaccinated  and 
unvaccinated   alike.      It   must   not  be  forgotten   that  even 


40  THE    DIAGNOSIS    OF    SMALLPOX 

among  imvaccinated  patients  the  eruption,  though  generally 
unmodified,  more  often  than  not  is  discrete.  In  such  cases 
the  individual  lesions  may  be  every  bit  as  virulent  as 
in  a  case  of  unmodified  confluent  smallpox ;  but  they  fail 
in  their  effect  from  lack  of  numbers.  The  peculiarities  of 
modified  smallpox  are  described  in  the  next  chapter. 

ABERRANT  ERUPTIONS  OF  CONFLUENT  SMALLPOX 

Confluent  papular  eruptions, — Cases  of  unmodified  dis- 
crete smallpox,  perhaps,  give  the  least  trouble  of  all  in 
diagnosis.  On  the  other  hand,  in  cases  of  confluent  smallpox 
the  diagnosis  is  sometimes  obscured  by  the  very'  intensity  of 
the  attack.  In  most  cases  the  epithet  "  confluent "  does  not 
apply  until  the  stage  of  suppuration.  Yet  the  rash  is  conflu- 
ent, sometimes,  even  in  the  papular  stage.  The  pustule  may 
be  taken  to  be  of  more  than  twice  the  diameter  of  the  largest 
papule.  The  area  occupied  by  the  rash,  therefore,  increases 
more  than  fourfold.  For  that  reason,  to  be  confluent  in  the 
papular  stage  the  lesions  must  be  brought  forth  in  great 
multitude,  and  such  cases  are  almost  always  fatal.  (Plates 
XLViii.  and  LVL,  Fig.  1.)  The  small  red  papules,  each 
surrounded  by  its  narrow  areola  and  projecting  but  shghtly 
above  the  surface  of  the  skin,  crowd  into  one  another  and 
lose  their  identity.  The  face  looks  fiery  red,  and  shows  an 
unbroken  surface.  The  skin  is  thickened,  but  the  par- 
ticulate nature  of  the  rash  can  hardly  be  perceived.  The 
surface  is  but  roughened,  and  feels  like  russian  leather. 
This  absence  of  discontinuity  in  the  rash  gives  it  a 
superficial  likeness  to  that  of  measles.  And  the  resemblance 
is  not  impaired  by  the  fact  that  with  smallpox  the  papules, 
though  confluent  on  the  face,  may  be  distinct  on  the  rest 
of  the  body ;  for  that  may  be  the  case  with  measles  also. 
In  many  cases  a  careful  examination  of  the  lesions  on  the 
trunk  and  limbs  will  disclose  their  proper  character.  Yet 
it  often  happens  that  the  individual  papules  depart  from 
the  type  so  much  that  their  nature  is  liable  to  be  mistaken. 
The  character  of  these  aberrant  lesions  is  very  important 


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PLATK  XLVHI. 

A  patient  with  severe  confluent  smallpox.  The  face  was  covered  with  a  profuse 
papular  eruption.  It  will  be  noticed  that  in  this  state  there  was  little 
alteration  of  the  natural  features.  The  point  is  not  very  well  shown  in  the 
print,  but  the  rash  displayed  an  abrupt  transition  of  density  on  the  neck 
at  the  collar-line  (compare  Plate  liv.,  Fig,  1). 


PLATE  XLIX. 


In  this  case  the  attack  was  of  a  severity  comparable  to  that  of  the  last.  The  eruption 
here  depicted  was  pustular.  The  natural  features  were  obliterated,  and  the  patient, 
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PLATE   LVI. 


Fig.  1. — From  a  case  of  confluent  smallpox  of  the  severest  kind.    The  rash  was  wholly 

papular,  but  was  already  confluent  on  all  parts  of  the  face. 
Fig*   2. — A  confluent  pustular  eruption,  virulent  in  type.     On  the  face  the  inflammatory 

reaction  was  feeble,  and  the  lesions  were  flat  and  flaccid.     Compare  the  pustules  on 

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PLATE  L1X. 

In  this  print,  the  last  of  the  series,  the  emption,  which  sliould  have  been  reaching  its 
maturitv,  is  shown  to  have  already  become  incrusted.  Even  tlie  swelling  of  tlie 
features'  depicted  in  the  last  print,  had  subsided.  In  this  case  the  lesions  on  tlie  face 
were  of  a  kind  very  common  with  modified  smallpox.  They  were  small,  but  had 
fleshy,  deep-seated  bases.     Suppuration  was  confined  to  their  crowns,  or  they  failed 

^  whoUv  to  suppurate  (compare  Plates  LXiii.,  Fig.  2,  and  LXIV.,  Fig.  1). 


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PLATE  LXII. 


Fig.  1.— Vesicles  of  modified  smallpox.  The  lesions  were  small  and  had  rounded  summits, 
but  otherwise  displayed  the  ordinary  characteristics  of  vesicles  of  smallpox. 

Fig.  2. — In  this  case  the  lesions  were  minute  and  superficial.  Many  of  them  were  no  bigger 
than  the  head  of  a  pin,  and  became  incrusted  without  suppurating. 


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PLATE   LXV, 


The  print  depicts  the  wart-like  masses  of  granulation-tissue  which  in  certain 
cases  of  modified  smallpox  are  left  after  the  separation  of  the  crusts.  The 
photograph  was  taken  after  convalescence  was  well  established. 


THE  ERUPTION  AND  THE  ERUPTIVE  FEVER   41 

to  recognise,  and  also  the  fact  that  they  may  be  produced 
by  somewhat  different  causes,  and  therefore  may  occur,  not 
only  in  this,  but  also  in  some  other  types  of  cases. 

Aberrant  eruptions— causes  and  effects, — The  character 
to  be  assumed  by  the  lesions  Avhich  may  be  developed  in  a 
case  of  smallpox  depends  upon  two  factors,  the  potency  of  the 
virus  lodged  in  the  skin,  and  the  power  of  the  tissues  to  resist 
it.  In  most  cases  of  natural  smallpox  there  is  an  equal 
tight.  Some  havoc  is  wrought  by  the  poison;  but  there  is 
a  healthy  resistance  of  the  tissues  shown  by  the  effusion  of 
serum,  by  cell-intiltration,  and  by  other  signs  of  inflamma- 
tion. In  some  cases,  where  the  immunity  of  the  patient  is 
high,  the  fight  goes  all  in  favour  of  the  tissues.  Repair  pre- 
dominates over  destruction,  and  such  lesions  are  met  with  as 
wiU  fall  to  be  described  in  the  next  chapter.  In  other  cases 
the  battle  goes  the  other  way.  The  virus  is  too  strong,  or 
the  tissues  are  too  weak.  There  is  destruction  of  tissue  and 
but  little  attempt  at  resistance.  The  tissues  do  not  show 
fight,  and  the  effect  is  seen  in  a  soft  papular  rash  imd,  later 
on,  in  flat  and  flaccid  vesicles.  (Plate  lvl,  Fig.  2.)  There  is 
little  or  no  exudation  of  serum,  and  the  vesicle  is  less  like  a 
bag  of  fluid  than  a  superficial  slough  of  the  epidermis. 

Such  a  lack  of  resistance  as  causes  these  sluggish  lesions  is 
met  with  in  somewhat  different  groups  of  cases.  It  may  be 
due  to  an  overwhelming  severity  of  attack,  as  in  those  cases 
of  ultra-severe  confluent  smallpox  described  above.  But  it 
may  be  due,  not  so  much  to  the  virulence  of  the  focal  rash,  as 
to  the  patient's  constitutional  condition ;  as,  for  instance,  when 
a  patient  who  sustains  an  attack  of  confluent  smallpox  is 
already  the  subject  of  a  prostrating  malad}',  such  as  tuber- 
culosis. It  is  seen  in  those  cases  of  ha?niorrhagic  smallpox  in 
which  life  is  prolonged  into  the  eruptive  stage.  (Plate  Lxxxix.) 
With  hemorrhagic  smallpox  the  papular  rash  is  not  neces- 
sarily of  the  first  degree  of  severity.  Yet  the  character  of  the 
disease  so  swamps  the  patient's  vitality  that  his  tissues  have 
no  power  to  resist  the  virus  which  is  deposited  in  the  skin. 
Indeed  the  primary  toxseraia  of  natural  smallpox,  if  the 
poisoning  be  severe  enough,  will  produce  the  same  effect.      It 


42  THE    DIAGNOSIS    OF    SMALLPOX 

will  be  seen  later  that  in  some  cases  the  toxtemia  is  attended 
by  the  severest  prostration.  And  while  that  prostration  lasts, 
its  effect  is  to  occasion  a  similar  want  of  reaction  in  the  lesions. 
In  such  cases  it  is  remarkable  to  observe,  when  the  fever 
abates  at  the  end  of  the  vesicular  stage,  how  the  lesions  swell 
up  and  take  on  a  healthy  reaction. 

Just  as  deficient  vitality  in  the  patient  is  capable  of  alter- 
ing the  character  of  the  lesions,  so  it  may  hinder  their 
development.  The  change  of  the  papule  into  the  vesicle, 
and  of  the  vesicle  into  the  pustule,  is  due  as  much  to  the 
reaction  of  the  tissues  as  to  the  action  of  the  virus ;  and  a 
feeble  tissue-action  may  cause,  not  only  anomaly  of  character, 
but  delay  in  transformation  also.  The  vesicle  is  late  to  come, 
and  the  vesicular  stage  is  dragged  out.  In  ordinary  cases 
the  interval  from  the  birth  of  the  papule  to  the  advent  of 
suppuration  is  about  four  days.  In  the  cases  under  dis- 
cussion the  interval  may  be  prolonged  to  five,  six,  or  even 
seven  days. 

Smallpox  is  not  suggested  by  an  eruption  consisting  of  a 
flush  of  soft  papules,  of  a  character  more  natural  to  measles, 
which  change  so  slowly  to  flat,  grey,  sodden  plaques,  having 
little  elevation,  no  serous  contents,  no  umbilication,  none  of 
the  characters  proper  to  variolous  lesions.  That  such  cases 
are  sometimes  watched  throughout  their  course,  without 
suspicion  of  the  real  nature  of  the  disease,  would  be  less 
remarkable  did  not  the  distribution  of  the  eruption  so  openly 
betray  it. 


CHAPTER  YII 

MODIFIED    SMALLPOX 

Immunity — natural  and  acquired. — By  the  use  of  the 
terms  "  modified  smallpox "  and  "  abortive'  lesions,"  no 
assumption  is  made  as  to  the  state  of  the  patient  with 
regard  to  vaccination.  All  that  is  implied  is  that  he 
exhibits  lesions  which,  in  certain  particulars,  differ  from 
the  type  most  common  among  un vaccinated  patients.  The 
papules,  instead  of  developing  into  the  large  vesicles  and 
pustules  of  natural  smallpox,  are  transformed  into  lesions 
which  are  generally  smaller  and  often  of  a  different  con- 
formation, which  do  not  form  pustules  of  the  usual  size  or 
wholly  fail  to  suppurate,  and  which  hasten  through  their 
course  of  evolution  more  quickly  than  is  natural. 

The  pathological  significance  of  this  kind  of  eruption  has 
already  been  explained.  There  is  a  high  power  of  resistance 
to  the  virus  provoking  the  inflammation  and,  in  consequence, 
processes  of  repair  predominate  over  those  of  destruction.  In 
other  words,  the  patient  is  partly  immune  to  the  poison  of 
the  disease.* 

But  immunity  may  be  exhibited  in  a  different  fashion.  A 
patient's  attack  may  be  a  mild  one,  not  because  the  lesions 
display  certain  favourable  characteristics,  but  because,  irre- 
spectively of  the  essential  character  of  its  elements,  the  rash 
itself  is  sparse.  A  patient's  susceptibility  is  to  be  measured, 
therefore,  not  only  by  the  presence  or  absence  of  modification 
of  his  lesions,  but  also  by  the  numerical  severity  of  his 
attack. 

These  different  manifestations  of  immunity  may  occur 
conjointly,  or  the  one  independently  of  the  other.     A  patient 

*  It  is  convenient  to  use  the  word  "  immunity  "  as  a  relative  term,  and  not 
as  synonymous  with  "  complete  insusceptibility  to  the  disease." 

43 


44  THE    DIAGNOSIS    OF    SMALLPOX 

may  be  immune  by  gift  of  nature  or  of  art.  If  by  art,  the 
eruption  is  generally  mild  as  well  as  modified;  but  not  in- 
frequently the  rash,  though  modified,  is  yet  numerically 
severe.  When  immunity  is  inborn,  the  eruption  is  generally 
mild  but  altogether  unmodified.  Yet  it  is  important  to  bear 
in  mind  that,  amonsr  the  unvaceinated,  there  are  some  cases 
in  which  the  rash  is  not  only  mUd  but  modified  as  well 
(Plate  LVIL,  Fig.  1),  and  others,  more  exceptionall}-,  in  which 
it  is  modified  though  numericaUy  severe.  It  will  be  observed 
then,  in  the  first  place,  that  the  term  "modified  smallpox" 
postulates  nothing  about  numerical  severity  of  attack,  and,  in 
the  second  place,  that  to  confer  immunity  by  vaccination  is 
merely  to  produce,  by  artifice,  a  natural  effect 

Injluence  of  vaccination. — Almost  all  people  are  bom 
susceptible  to  smallpox,  though  not  equal  in  susceptibility. 
Among  the  unvaccinated  the  attack,  in  the  bulk  of  cases,  is 
of  mean  severity ;  most  patients  experience  the  severer  forms 
of  discrete  smallpox  or  the  milder  forms  of  confluent  Those 
whose  natural  susceptibility  diverges  from  this  mean  are 
fewer  and  fewer  according  to  the  extent  of  the  divergence; 
and  there  are  comparatively  few  of  the  unvaccinated  who  are 
liable  either  to  the  most  severe  or  to  the  very  mildest  attacks. 

Whatever  his  natural  susceptibility  may  have  been,  when 
a  person  for  the  first  time  is  vaccinated  the  immediate  effect 
is  such  an  augmentation  of  his  natural  immunity  as  to  make 
him  wholly  insusceptible.  With  the  lapse  of  years  the 
immunity  so  acquired  will  wane,  and  after  a  suflBcient  interval 
of  time  wUl  wholly  disappear,  leaving  him  just  that  modicum 
of  natiu^al  immunity  with  which  he  started.  Should  he  get 
smallpox  then,  he  would  get  an  attack  of  just  that  severity 
which  he  would  have  experienced  had  he  never  been  vaccinated 
at  all 

Now  should  such  a  person  get  smallpox  in  the  interval, 
before  his  acquired  immunity  has  worn  away,  he  would  be 
open  to  an  attack  of  any  degree  of  numerical  severity  up 
to  the  limit  set  by  his  natural  immunity.  He  might  even 
reach  that  limit  yet  still  preserve  a  residuum  of  acquired 
immunity.     A  person,  indeed,  who  has  lost  just  so  much  of 


MODIFIED    SMALLPOX  45 

his  acquired  iinraunity  as  to  render  him  liable  to  smallpox 
of  that  numerical  severity  to  which  he  was  by  nature  liable, 
has  by  no  means  lost  all  his  protection,  and  if  he  were 
attacked  would  have  an  eruption  still  considerably  modified. 
The  two  faculties  of  the  vaccinal  immunity  wane  together; 
but  the  protective  inHuence  against  numerical  severity  of 
attack  goes  quicker,  and  the  faculty  to  cause  an  eruption  to 
be  modified  is  retained  for  years  after  the  other  faculty  has 
been  wholly  lost.  The  duration  of  each  kind  of  acquired 
immunity  varies  with  different  people.  With  some,  imnumity 
of  both  sorts  is  lost  in  less  than  twenty  years ;  with  others, 
traces  remain  for  a  lifetime. 

The  fact,  that  with  the  gradual  attrition  of  vaccinal 
immunity  the  power  of  checking  the  numerical  severity  of 
attack  goes  first  and  the  faculty  of  modifying  the  lesions 
lasts  longer,  has  the  notable  consequence,  already  alluded  to, 
that  vaccinated  patients  often  get  eruptions  which,  though 
modified,  are  of  considerable  numerical  severity.  For,  taking 
the  large  class  of  those  who  have  lost  their  protection  against 
numerical  severity  of  attack  but  retain  that  against  virulence 
of  lesion,  the  members  will  be  arranged  after  just  the  same 
plan  as  governs  the  severity  of  attack  among  the  unvac- 
cinated,  and  most  of  them  will  be  liable  to  attacks  of  mean 
numerical  severity.  This  does  not  imply  that  smallpox 
among  the  vaccinated  is  generally  of  mean  numerical 
severity ;  for,  in  the  still  larger  class  of  those  who  have 
not  yet  lost  protection  against  numerical  severity  of  attack, 
discrete  smallpox  predominates  and  swamps  the  severer 
cases  in  the  former  class.  Smallpox  of  the  vaccinated, 
therefore,  differs  from  smallpox  of  the  unvaccinated,  not 
only  in  the  preponderance  of  mild  and  modified  cases,  but 
also  in  the  fact  that  even  those  who  get  the  more  severe 
attacks  will  be  likely  to  exhibit  more  or  less  modified 
eruptions. 

Confluent  eruptions  modified. — When  a  patient  suffers 
an  attack  of  smallpox  with  a  well-modified,  confluent  erup- 
tion, the  course  of  the  illness  is  very  surprising  to  the 
observer.     It  begins  with  a  severe  toxaemia,  and  the  patient 


46  THE    DIAGNOSIS    OF    SMALLPOX 

gets  a  thick  rash  of  papules  which  have  no  feature  beyond 
the  ordinary.  There  is  nothing  to  dispel  the  shadow  of 
threatened  events.  Not  until  the  vesicular  change  is  well 
advanced,  or  suppuration  has  begun,  does  the  benign  char- 
acter of  the  rash  deckre  itself  (Plates  Lvii.,  Fig.  2,  Lviii., 
and  Lix.)  When  suppuration  sets  in,  the  patient,  who 
should  be  ill,  feverish,  and  prostrate,  whose  bloated  features 
should  be  covered  ^nth  large,  wart-like  pustules,  throws  off 
his  symptoms  and  is  encumbered,  but  not  enchained,  by  a 
rash  which  strews  his  face  with  a  mere  stubble  of  pus-capped 
pimples.     (Chart  v.,  p.  38.) 

Nevertheless,  modified  smallpox  may  be  a  fatal  disorder. 
For,  in  broad  terms,  the  liability  to  death  depends  upon 
the  measure  of  the  total  suppurative  process.  Unless  the 
abortive  character  be  very  well  marked,  suppuration,  though 
reduced  in  amount,  is  in  modified  lesions  by  no  means 
absent.  In  a  case  of  confluent  smallpox,  numerically  severe 
yet  slightly  modified,  the  amount  of  suppuration  may  be 
the  equivalent  of  that  in  a  case  of  natural  smallpox  of  a 
numerical  severity  which  is  only  moderate  ;  and  this  amount 
of  pus-formation  may  be  sufiicient  to  determine  a  fatal  issue 
in  each  case.  The  fact  is,  that  it  takes  more  rash  to  kill 
when  the  rash  is  modified,  and  that  it  takes  more  and  more 
rash  to  kill  according;  to  the  dcOTee  of  modification. 

Eruptions  incompletely  modified. — It  must  be  under- 
stood that  the  character  of  the  lesions  is  not  necessarily 
uniform  in  a  particular  case.  There  is  no  distinct  dividing 
line  between  modified  and  natural  smallpox.  In  most  cases 
of  natural  smallpox — whether  the  patient  has  or  has  not 
been  vaccinated  is  immaterial — a  minority  of  the  lesions 
are  small  or  abortive.  (Plate  xlvi.)  In  such  cases  the 
eruption  is  not  described  as  modified,  because  there  is  an 
immense  preponderance  of  lesions  which  are  not  atypical. 
When  atypical  lesions  preponderate  or  contribute  to  the  rash 
in  large  proportion,  the  eruption  is  said  to  be  modified  more 
or  less  completely.  Modification  is  always  most  in  evidence 
on  the  face,  and  it  may  be  displayed  by  the  bulk  of  the 
lesions  developed  in   that   situation  Avhen   it  is  lacking   to 


MODIFIED    SMALLPOX  47 

those  on  other  parts  of  the  body.  But  these  incompletely 
modified  eruptions  often  exhibit,  both  on  the  face  and  else- 
where, the  greatest  diversity  in  the  character  of  the  lesions 
which  exist  side  by  side ;  some  may  be  quite  abortive,  others 
only  slightly  modified,  and  others  again  may  be  natural. 
(Plates  LX.  and  xl.)  The  kind  of  rash,  which  occurs  in  a 
case  in  which  the  whole  vaccinal  immunity  has  almost  dis- 
appeared, is  such  a  mixed  rash  of  natural  and  modified 
lesions.  It  is  that  kind  of  borderland  case  which  is  so  apt 
to  be  fatal  if  the  rash  is  sufficiently  abundant. 

Characteristics  of  modified  lesions.— The  various  types 
round  which  modified  lesions  may  be  grouped  are  to  some 
extent  characteristic  of  different  cases,  but  in  many  cases 
lesions  of  diverse  type  are  commingled. 

When  the  eruption  is  in  the  papular  stage  it  is  seldom 
possible  to  distinguish  modified  from  natural  smallpox,  and  it 
is  not  until  the  lesions  have  become  vesicular  or  pustular  that 
the  differences  become  manifest.  In  many  instances  the 
difference  is  almost  wholly  of  size,  and  the  lesions  merely  re- 
produce on  a  reduced  scale  the  characteristics  of  normal 
lesions.  (Plates  lxi.  and  lxii.,  Fig.  1.)  Sometimes  this  copy- 
ing in  miniature  is  carried  to  an  extreme.  The  irritative 
action  of  the  virus  is  then  so  slight  as  to  evoke  only  an  insig- 
nificant reaction  of  the  tissues ;  and,  though  the  lesions  may 
not  differ  materially  in  shape  from  those  of  natural  smallpox, 
they  are  much  more  superficial  and  very  rapid  in  evolution. 
(Plate  Lxii.,  Fig.  2.) 

Sometimes  the  difference  is  not  so  much  in  size  or  shape 
as  in  depth  of  situation  only,  and  lesions  are  found  which, 
while  of  moderate  size,  are  obviously  superficial  and  perhaps 
unloculated.  (Plate  LXiii.,  Fig.  1.)  Lesions  of  this  kind  are 
peculiarly  apt  to  occur  on  the  soft  skin  of  the  trunk,  and  on 
those  parts  may  sometimes  be  met  with  even  in  cases  of 
natural  smallpox. 

With  lesions  of  another  type,  though  there  may  be 
differences  from  natural  lesions  in  size  and  shape,  the  root- 
character  of  the  difference  lies  in  the  inflammatory  process. 
Under  these  circumstances  the  irritant  which  provokes  the 


48  THE    DIAGNOSIS    OF    SMALLPOX 

lesion,  though  insufficient  to  cause  so  much  destruction  of 
tissue  as  in  a  case  of  natural  smallpox,  is  nevertheless  capable 
of  evoking  a  very  pronounced  reaction  which  is  displayed  by 
the  formation  of  new  cell-tissue  in  the  base  of  the  lesion. 
These  lesions  lose,  in  part,  the  character  of  an  abscess  and 
take  on  something  of  the  nature  of  a  granuloma.  They  con- 
sist of  fleshy  elevations  with  shelving  sides,  and  are  deeply 
rooted  in  the  skin.  (Plates  lxiii.,  Fig.  2,  and  lxiv.,  Fig.  1.)  At 
the  top  of  the  mass  there  is  a  more  or  less  imperfect  vesicle 
or  pustule.  Though  they  are  of  a  different  structure,  such 
lesions  may  be  just  as  big  as  those  of  natural  smallpox.  They 
are  developed  chiefly  on  the  face  ;  and,  in  that  situation,  they 
are  apt  to  leave  wart-like  excrescences  which  persist  long 
after  the  recovery  of  the  patient.    (Plate  lxv.) 

Lesions  of  this  peculiar  nature  are  most  characteristic 
when  they  are  large.  Smaller  lesions  of  the  same  kind  are 
less  readily  distinguished  from  some  of  the  varieties  already 
described,  into  which,  indeed,  they  imperceptibly  merge. 
Yet,  especially  on  the  face,  even  the  more  perfectly  modified 
and  smaller  lesions  are  apt  to  take  on  something  of  the  same 
character ;  that  is  to  say,  to  assume  the  form  of  a  cone-shaped 
fleshy  base  surmounted  by  a  small  vesicle  or  pustule.  (Plates 
LXIV.,  Fig.  2,  and  lix.)  In  some  instances,  no  sign  of 
vesiculation  is  ever  apparent;  and  the  lesion,  though 
persistent,  may  be  said  never  to  advance  beyond  the 
papular  stage. 

Diagnosis. — The  large  lesions  of  the  less  modified  erup- 
tions have  solid  bases,  well  defined  to  the  touch,  and  embedded 
deeply  in  the  skin.  Despite  their  different  aspect,  they  are 
as  easy  of  recognition  as  are  the  lesions  of  natural  smallpox. 
Of  the  lesions  which  arQ  smaller  and  more  abortive  it  is  harder 
to  be  sure.  For,  in  proportion  as  they  are  more  altered,  their 
position  in  the  skin  is  more  superficial  and  they  are  lacking 
in  those  signs  on  which  their  recognition  depends.  It  seems 
to  be  a  law  that  the  more  susceptible  the  patient,  the  more 
deeply  placed  are  his  lesions.  It  is  as  though,  with  increasing 
immunity,  the  virus  must  escape  further  from  the  blood-bear- 
ing papillary  layer  and,  under  the  least  favourable  conditions 


MODIFIED    SMALLPOX  49 

can  maintain  itself  only  in  those  bloodless  fastnesses  of  the 
upper  epidermis  near  where  the  lesion  of  chickenpox  inhabits. 

In  such  cases  many  of  the  lesions  have  no  characteristic 
by  which  it  is  possible  to  distinguish  them  from  those  of 
chickenpox.  Yet,  if  the  patient  be  seen  before  the  pustules 
die  and  scab  over,  their  real  nature  is  generally  betrayed  by 
some  of  them.  With  a  rash  of  scabs  the  thing  is  different, 
for  nice  distinctions  of  depth  cannot  then  be  appreciated.  An 
added  difficulty  is  that,  since  highly  modified  rashes  signalise 
a  high  degree  of  immunity,  they  are  commonest  among 
children,  because  children  are  not  too  far  advanced  in  years 
from  the  date  of  vaccination.  And  in  the  case  of  a  child,  on 
other  grounds,  chickenpox  is  often  the  most  likely  diagnosis. 
Under  such  circumstances,  even  when  the  rash  is  scanty,  its 
distribution  must  be  the  cardinal  factor  in  diagnosis. 

Begradatian  of  strain. — The  severity  of  an  attack  of 
smallpox  depends,  really,  on  something  more  than  the 
measure  of  the  patient's  immunity.  For,  with  all  infectious 
diseases  and  perhaps  with  smallpox  more  than  most,  the 
strain  of  disease  varies  in  virulence  in  different  epidemics ; 
some  are  attended  by  a  low  fatality,  others  by  a  high.  The 
severity  of  attack  measures  the  resultant  of  the  two  opposing 
forces,  the  patient's  immunity,  and  the  virulence  of  the 
infective  agent.  The  effect  is  that,  in  a  mild  epidemic,  the 
proportion  of  mild  and  modified  cases  is  much  greater  than 
irf  an  epidemic  of  a  severer  type,  and  that  the  difficulties  of 
diagnosis  are  proportionately  increased. 

From  time  to  time  we  hear  of  epidemics  in  which  the 
illness  is  so  inconsiderable,  and  the  eruption  of  so  anomalous 
a  character,  that  there  is  some  hesitation  about  the  name.  If 
the  rash  be  unlike  that  of  smallpox,  it  difiers  equally  from 
that  of  chickenpox,  and  opinion  inclines  sometimes  one  way 
and  sometimes  the  other.  There  may  be  a  temptation  even 
to  assume  the  existence  of  a  third  disease,  and  to  invest  it 
with  points  of  distinction  from  each. 

This  flux  of  opinion  is  caused  by  the  prevalence  of  small- 
pox of  a  very  degraded  strain  of  virulence.  In  every  epidemic 
cases  arise  at  intervals  in  which  the  eruption  is  so  highly 


60  THE    DIAGNOSIS    OF    SMALLPOX 

modified  and  the  character  of  the  lesions  is  so  anomalous 
that  there  is  an  inadequate  basis  for  diagnosis;  and,  given 
an  epidemic  mild  enough,  such  cases  may  form  the  bulk. 
Yet  it  must  not  be  forgotten  that  it  is  not  possible  for  dis- 
cordant distributions  to  run  in  series  also.  However  much 
the  lesions  may  be  altered  in  character,  the  scheme  of  their 
arrangement  will  not  be  influenced  either  by  the  suscep- 
tibility of  the  patient  or  by  the  strain  of  the  disease. 


CHAPTER  VIII 

SECONDARY   CHARACTERISTICS  OF   THE   ERUPTION 

There  are  certain  features  of  the  eruption  which,  though 
generally  of  subordinate  interest,  come  occasionally  into 
the  first  rank  of  importance.  An  example  of  a  case  in  which 
these  secondary  characteristics  determined  the  diagnosis  is 
furnished  by  Plate  Lxvi.  The  rash  was  a  syphilide.  Though 
most  of  the  usual  distinguishing  features  were  lacking,  three 
facts  may  be  deduced  from  the  print,  by  which  smallpox  could 
be  safely  excluded.  In  the  first  place,  many  of  the  lesions 
were  too  large.  Again,  to  some  of  these  larger  lesions  there 
was  lacking  a  regular  circular  outline.  Lastly,  the  elements 
of  the  eruption  were  not  homogeneous ;  the  rash  was  com- 
posed, in  part,  of  lesions  which  had  become  incrusted,  in  part, 
of  smaller  pustules. 

Heterogeneous  eruptions. — A  want  of  uniformity  of 
character  in  the  lesions  is  a  conspicuous  feature,  especially, 
of  many  cases  of  chickenpox.  Yet,  whether  that  disease  or 
another  is  the  alternative  to  smallpox,  such  evidence  must  be 
interpreted  with  discrimination.  Merely  that  the  eruption 
is  heterogeneous  does  not  count  for  much,  for  it  may  be 
heterogeneous  with  smallpox.  The  rapidity  of  evolution  of 
variolous  lesions  is  determined  chiefly  by  their  size  and  by 
their  depth  of  situation.  In  cases  of  smallpox  incompletely 
modified,  cases  in  which  the  lesions  differ  considerably  in 
point  of  size,  they  will  differ  equally  in  rapidity  of  evolution. 
There  are  cases  of  modified  smallpox  in  which,  for  this  reason, 
the  want  of  uniformity  among  the  lesions  is  a  very  conspicu- 
ous feature.  (Plate  lxiii..  Fig.  1.)  Papules  arrested  in  de- 
velopment, vesicles,  pustules,  crusts  may  all  lie  together  on  the 
same  square  inch  of  surface.  Moreover,  even  with  natural 
smallpox  the  outcrop  is  a  gi-adual  process,  and  the  firstborn 

51 


52  THE    DIAGNOSIS    OF    SMALLPOX 

lesions  get  ahead  of  their  neighbours  and  show  a  correspond- 
ing difference  of  character. 

What  is  to  the  point  is  that  with  smallpox  the  diversity 
of  character  is  orderly.  The  smaller  the  lesion,  and  the 
nearer  it  lies  to  the  face,  the  greater  should  be  its  apparent 
age.  In  cases  of  chickenpox  or  of  syphilis  the  diversity  is 
fortuitous.  The  smaller  vesicles  or  pustules  may  be  inter- 
mingled with  larger  crusts  ;  and  the  older  lesions  may  be 
found  upon  the  face,  or  upon  the  trunk,  or  upon  the  leg. 

Rapidity  of  evolution. — The  rapidity  of  evolution,  the 
inconstancy  of  which  is  a  cause  of  the  heterogeneous 
character  of  certain  variolous  eruptions,  is  itself  in  some  cases 
pertinent  to  the  problem  of  diagnosis.  Ordinarily  the  erup- 
tion is  pustular  throughout  within  eight  or  nine  days  of  the 
outcrop,  and  on  the  face  some  two  days  earlier.  The  cases  of 
smallpox  in  which  those  Umits  are  exceeded  are  conspicuously 
distinguished  by  the  severity  of  the  constitutional  symptoms 
and  by  the  anomalous  character  of  the  rash.  {See  Chapter  vi., 
p.  42. )  Eruptions  of  ordinary  character,  consisting  of  vesicles 
wholly  or  in  part,  are  therefore  unhkely  to  be  variolous  if  their 
age  exceeds  a  week.  Smallpox  can  be  less  safely  excluded 
on  account  of  undue  rapidity  of  evolution.  Only  when  the 
lesions  approximate  in  size  to  those  proper  to  natural  smallpox 
can  the  rapidity  of  their  maturation  be  adduced  as  rebutting 
evidence. 

Shape  and  Size. — Marginal  outline  furnishes,  sometimes, 
even  more  convincing  evidence  against  smallpox  than  in  the 
case  quoted  at  the  beginning  of  the  chapter.  The  usual 
shape  of  the  variolous  vesicle  or  pustule  is  circular.  A  pear- 
shaped  or  asymmetrical  outline  is  produced  very  frequently 
by  a  double  or  compound  focus  of  origin ;  but  such  compound 
lesions  are  seldom  difficult  to  distinguish.  Not  infrequent, 
also,  are  single  vesicles  or  pustules  with  an  outline  which  is 
slightly  oval ;  these  are  met  with  most  often  in  cases  of  modi- 
j&ed  smallpox.  (Plate  cviii.,  Fig.  1.)  But  oval  vesicles  are, 
really,  far  more  characteristic  of  chickenpox,  the  sign  being 
secondary  to  the  superficial  situation  of  the  lesion ;  indeed,  the 
peculiarity  is  of  some  consequence  in  the  diflferential  diagnosis 


ERUPTION :     SECONDARY    CHARACTERISTICS  53 

of  the  two  diseases.  (See  p.  119.)  A  distinction  even  more 
striking  lies  in  the  sinuous  or  jagged  outhne  of  many  chicken- 
pox  vesicles.  (Plate  cvm.,  Fig,  2.)  Even  though  it  may 
depart  from  the  round,  the  outline  of  a  variolous  lesion  is 
seldom  otherwise  than  firm  and  regular.  There  are  other 
diseases  besides  chickenpox  with  which  an  oval  or  irregular 
outline  of  the  lesions  may  be  a  useful  point  of  distinction. 

Much  less  frequent  are  cases  with  which  the  size  of  the 
lesions  is  a  material  consideration.  Yet  there  are  some  which, 
though  most  of  the  lesions  come  within  the  possible  limits, 
may  be  excluded  by  the  size  of  a  few.  Pustules  or  scabs  half 
an  inch  across,  or  vesicles  of  a  diameter  even  less,  almost 
certainly  would  not  be  variolous.  A  downward  limit  of  size 
cannot  be  fixed. 

Blebs. — The  dimensional  rules  apply  only  to  the  specific 
lesions.  In  the  severer  cases  blebs  may  be  developed  and 
may  attain  a  considerable  size ;  but  they  are  not  specific  and 
are  never  very  numerous.  (Plate  lxvii.)  They  are  caused 
by  the  detachment  of  the  cuticle  owing  to  the  irritative  action 
of  the  specific  pustules.  They  are  of  little  importance;  for 
the  specific  lesions  which  have  evoked  the  bleb  can  be  readily 
discerned  to  lie  within  it,  and  there  is,  therefore,  little  risk  of 
misinterpretation. 

Proto-papubles  and  lesions-  of  inoculation. — There  is, 
however,  one  form  of  variolous  lesion  which  may  be  regarded 
as  an  exception  to  the  rules  in  the  matter  both  of  size  and  of 
shape.  In  dealing  with  the  outcrop  and  progress  of  the 
eruption,  the  events  in  its  evolution  are  dated  from  the  day 
when  the  papules  invade  the  face  in  number  sufficient  to  take 
account  of.  This  invasion  is  generally  sudden  and  distinct 
enough.  Yet,  sometimes,  there  are  a  few  scouts  which  pre- 
cede the  vanguard  of  the  army.  A  patient  will  point  to  one 
or  two  of  his  lesions  and  assert  their  appearance  a  day  or  two 
before  the  rest.  These  early  arrivals  come  mostly  on  the  face 
or  upper  part  of  the  body.  They  start  ahead  of  the  rest  in 
development  and  maintain  their  precedence.  And,  what  is 
more  noticeable,  they  are  larger  than  the  rest,  often  more 
deep-seated,  and  oval  or  a  little  irregular  in  outline. 


54  THE    DIAGNOSIS    OF    SMALLPOX 

From  their  size  and  shape  and  general  appearance  arises 
the  suggestion  that  in  some  cases  these  proto-papules  are 
lesions  of  inoculation.  A  patient  who  has  become  infected 
through  the  usual  channel,  the  respiratory  tract,  still  remains, 
during  the  period  of  incubation,  susceptible  to  an  inoculation 
through  the  skin.  It  may  be  that  the  evidence  of  inocu- 
lation is  convincing,  both  from  the  history  furnished,  and 
from  the  fact  that  the  lesions  are  exceptionally  large  and 
resemble  the  lesions  of  vaccination.  (Plate  lxviii..  Fig.  1.) 
Abnormal  lesions  of  these  kinds  are  enabling,  sometimes,  of 
an  exceptionally  early  diagnosis. 

Obsolescent  lesions. — One  may  have  to  judge  of  a  case 
of  smallpox  after  recovery  or  during  convalescence ;  what 
is  all-important  then  is  the  impression  which  the  rash  has 
left  upon  the  skin. 

Crusts. — The  crusts  separate  first  from  the  face,  trunk,  and 
upper  parts  of  the  limbs.  They  linger  longest  beneath  the 
thick  skin  of  the  palms  and  soles.  On  the  soles,  especially, 
they  may  persist  for  many  weeks  unless  extracted  artificially. 
These  "  seeds  "  have  a  very  characteristic  appearance.  (Plate 
LXVIII.,  Fig.  2.)  The  thick  cuticle  of  the  sole  lies  over  them 
and  they  do  not  interrupt  its  level  surface.  Through  this 
translucent  layer  the  brown  disc-like  scabs  can  be  clearly  dis- 
cerned embedded  in  the  skin  below.  This  evidence  is  valu- 
able, especially,  in  cases  of  the  milder  sort,  in  which  scars 
and  pigmentation-marks  are  absent  or  evanescent;  for  it 
may  bring  about  a  conviction  when  every  other  sign  of  the 
disease  has  failed. 

Scars  and  granulomata. — It  must  not  be  supposed  that 
even  natural  smallpox  invariably  scars,  or  that  all  parts  of  the 
body  are  equally  Uable  to  the  damage.  Scarring  is  most  con- 
spicuous on  the  face  (Plate  lxix.),  and  is  generally  confined  to 
the  face  or  to  the  face  and  hands.  In  the  worst  cases  the 
scalp  is  badly  scarred  and  suffers  a  patchy  alopecia.  The 
parts  that  suffer  most  of  aU  are  the  nose,  the  forehead  just 
above  the  root  of  the  nose,  and  the  cheeks.  In  these  situa- 
tions, the  patient  often  sustains  a  disfigurement  which  is  even 
more  trying  than  the  broad  deep  scars  themselves.     There  is 


ERUPTION:     SECONDARY    CHARACTERISTICS  55 

a  fine  pitting  of  the  skin,  whicli  is  relieved  by  the  projection 
of  points  and  strands  of  young  scar-tissue,  so  that  the  sur- 
face is  coarse  and  rough  Hke  a  nutmeg-grater.  (Plate  lxx.) 
Such  a  condition  is  commonest  among  those  who  have  had  a 
confluent  but  partly  abortive  eruption. 

An  effect  analogous  to  that  last  described,  and  one  apt  also 
to  be  evoked  by  a  partly  abortive  rash,  is  the  development  of 
wart-like  granulation-tumours.  These  were  mentioned  in  the 
last  chapter.  {See  p.  48,  and  Plate  lxv.)  They  are  most  fre- 
quent on  the  jaAvs  and  cheeks  and  nose,  and  are  seldom 
seen  on  other  parts  of  the  body  than  the  face,  except  some- 
times on  the  hands  and  forearms.  These  excrescences  persist 
for  many  weeks,  but  are  not  permanent. 

Desquamation. — Desquamation,  in  the  sense  in  which  the 
term  is  used  in  relation  to  scarlet  fever,  is  not  a  symptom  of 
smallpox.  Yet,  round  the  scar  or  mark  left  by  the  fallen  scab, 
the  cuticle  often  becomes  partly  detached  and  ragged.  This 
effect  is  most  in  evidence  where  the  cuticle  is  thick,  for 
example,  upon  the  limbs.  It  is  brought  about  directly  by  the 
damage  to  the  skin,  and  is  confined  to  the  immediate  neigh- 
bourhood of  the  injury.  Only  the  more  deeply  placed  lesions 
provoke  it.  In  severe  cases,  when  the  lesions  crowd  together, 
the  effect  may  be  pronounced  (Plate  lxxi..  Fig.  1),  but  it  is 
commonly  absent  or  inconspicuous  in  cases  of  modified 
smallpox. 

Pigmentation. — More  characteristic  are  the  areas  of  pig- 
mentation which  are  left.  (Plate  lxxii.)  When  the  attack  has 
been  moderately  severe,  the  impression  of  the  whole  eruption 
is  very  clearly  mapped  out  by  them,  and  these  spots  of  brown 
blood-pigment  are  very  lasting.  (Plate  lxxiii.,  Fig.  1.)  Where 
there  are  scars,  the  pigment  forms  a  halo  round  each  (Plate 
LXXI.,  Fig.  2) ;  but  in  most  places,  and  indeed  in  most  cases, 
pigmented  marks  upon  the  surface  are  the  only  relics  which 
remain. 

In  cases  of  natural  smallpox,  and  in  the  severer  cases  of 
all  kinds,  by  these  scars  and  pigmented  stains  the  disease 
can  be  told  for  many  weeks  after  the  patient's  recovery.  The 
distribution  is  as  obvious  as  when  the  rash  was  mature.     In 


56  THE    DIAGNOSIS    OF    SMALLPOX 

mild  and  modified  cases  the  trail  is  not  so  plain.  Scarring  is 
absent,  and  even  the  pigment  is  evanescent.  In  such  cases  it 
is  important  to  remember  that  the  rash  and  its  traces  go  first 
from  the  face,  where  repair  is  quickest.  Observation  must 
then  be  supplemented  by  inquiry  to  learn  the  true  distribution 
of  the  vanished  eruption. 

SEPTIC  RASHES 

During  the  period  of  involution  the  skin  is  attacked,  some- 
times, by  a  superficial  septic  dermatitis.  This  is  consequen- 
tial to  a  septic  infection  of  the  pustules,  and  reveals  itself  as 
an  erythema  spreading  at  numerous  points  from  the  infective 
lesions  as  foci. 

A  secondary  infection  of  the  pustules  by  septic  organisms 
is  of  common  occurrence  in  all  sorts  of  cases,  but  generally  no 
harmful  consequences  flow  from  it.  That  in  one  case  among 
many  the  infection  should  extend  into  the  superficial  layers  of 
the  contiguous  skin  is  attributable  to  defective  vitality  of  the 
tissues,  due  either  to  a  pre-existing  debility  or,  more  commonly, 
to  the  debilitating  effect  of  the  disease.  It  is  the  same  con- 
junction of  causes  as  provokes  such  complications  as  boils, 
abscesses,  and  affections  of  the  eye,  to  which  these  patients  are 
very  subject.  All  these  secondary  infections  are  most  apt  to 
appear  just  at  the  close  of  the  suppurative  fever,  when  they 
often  give  rise  to  a  definite  febrile  attack  which  finds  its  record 
on  the  temperature  chart.  {See  Charts  i.  and  ii.,  p.  4  and 
p.  34.) 

The  red  patches,  caused  by  the  septic  dermatitis,  at  first 
surround  the  infecting  lesions  after  the  manner  of  an  areola. 
As  the  patches  grow  bigger  they  merge  together  and  the  skin 
becomes  mottled  by  them.  (Plates  Lxxiii.,  Fig.  2,  and  lxxiv.) 
There  is  no  swelling  of  the  skin,  but  in  some  cases  small  thin- 
walled  vesicles  and  pustules  are  thrown  out  on  the  invaded 
surface,  more  especially  on  the  flanks  and  abdomen.  Those 
are,  indeed,  the  favourite  seats  of  the  rash,  and  to  them  it  may 
be  confined ;  but  in  the  more  severe  cases  the  best  part  of 
the  body  may  be  invaded.     Sometimes    especially  when  the 


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Fig,  1. — The  figure  shows  two  pustules  on  the  arm,  which  were  caused  by  the 
accidental  inoculation  of  variolous  matter  during  the  period  of  incubation 
of  a  generalised  attack.  The  evolution  of  the  generalised  eruption  is  not 
BO  far  advanced. 

Fig.  2.— The  soles  of  a  patient  convalescent  from  smallpox.  Tlie  brown  crusts 
were  still  firmly  embedded  under  the  thick  cuticle. 


PLATE   LXVIII. 


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PLATE   LXX. 

The  face  of  a  man  after  an  attack  of  confluent  modified  smallpox.  In  contrast  with  those 
represented  in  tlie  last  figure,  the  injuries  in  this  instance  were  in  the  nature  of 
addition  rather  tlian  of  subtraction  of  tissue.  In  many  places  («)  the  skin  had 
become  heaped  up  by  excessive  growth  of  young  scar-tissue.  Below  the  orbit  (ft  b  b) 
was  a  large  patch  where  the  skin  had  become  rough  and  irregularly  thickened. 


PLATE   LXXI. 

Fig.  1.— Extensive  desquamation  on  the  forearm  after  a  severe  attack  of  smallpox. 
Fig-  2.— The  back  of  a  patient  convalescent  after  smallpox.     The  white  scars  were  sur- 
rounded each  by  a  halo  of  brown  pigment. 


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SEPTIC    RASHES  57 

rash  is  extensive,  it  is  apt  to  lose  much  of  its  mottled 
character,  and  large  areas  may  be  covered  by  a  uniform  or 
stippled  erythema. 

The  affection,  as  indicated  above,  is  accompanied  by  some 
fever  and  malaise  and,  it  may  be,  by  a  sore  throat.  It  is 
never  dangerous.  Its  chief  importance  resides  in  the  fact  that 
it  is  liable  to  be  mistaken  for  scarlet  fever  or  measles  compli- 
cating an  attack  of  smallpox.  Confusion  with  measles  is  less 
likely,  but,  if  scarlet  fever  is  a  possible  alternative,  it  may  be 
very  difficult  to  exclude  it  on  the  merits  of  the  case. 


CHAPTER    IX 

THE    TOX/EMIC     FEVER 

Of  this  dual  disease,  the  foregoing  chapters  have  been  occupied 
with  that  part,  the  focal  rash  and  the  secondary  fever,  which 
is  generally  the  all-in-all  both  to  the  patient  and  to  the 
physician.  Yet,  pathologically,  that  part  is  an  excrescence  on 
the  other,  a  comphcation  or  a  sequela.  To  the  specific  fevers 
themselves,  the  secondary  fever  of  smallpox  bears  no  analogy. 
The  fever  proper  of  smallpox  is  that  of  the  septictemia,  and 
the  focal  rash  and  the  secondary  fever  bear  the  same  relation 
to  it  as  the  pneumonia  to  measles  or  the  adenitis  to  scarlet 
fever. 

The  variolous  septicemia,  or  rather  the  toxaemia  which  it 
induces,  though  often  insignificant  in  its  symptoms  and 
results,  is  still  a  serious  phase  of  the  illness.  If  natural 
smallpox  could  be  shorn  wholly  of  the  fatal  fever  of  suppura- 
tion, a  disease  would  remain  comparable  to  scarlet  fever  in  its 
fatality.  For  the  variolous  toxaemia  can  be  fatal  enough, 
though  it  is  the  custom  to  classify  the  graver  forms  of  it 
under  the  title  of  hsemorrhagic  smallpox.  These  graver  cases 
will  be  discussed  in  succeeding  chapters,  after  the  milder  types 
of  illness  have  been  described  and  the  toxsemic  rashes  which 
so  often  accompany  them. 

Symptoms. — The  toxsemic  symptoms  are  not  very  charac- 
teristic. There  is  every  variety  in  their  severity  and  duration, 
and  they  furnish  scanty  grounds  for  a  guess  as  to  the  nature 
of  the  illness  unless  the  patient  is  known  to  have  been  ex- 
posed to  variolous  infection.  The  symptoms  do  not  difier 
materially  from  those  of  some  other  specific  fevers  or,  indeed, 
from  the  symptoms  of  onset  of  several  acute  diseases.  The 
toxemic  symptoms  are  not  usually  attributed  to  another 
specific  fever  unless  associated  with  a  toxsemic  rash.     They 

n 


THE    TOX.EMIC    FEVER  59 

are  most  commonly  put  down  to  influenza  or  to  a  common 
cold,  from  the  symptoms  of  which  they  often  present  no 
distinguishing  feature.  Less  often,  and  perhaps  with  less 
reason,  the  patient  is  supposed  to  be  suffering  from  pneumonia, 
or  acute  rheumatism,  or  meningitis.  Such  misinterpretations 
are  of  little  moment  in  the  earliest  stage  of  the  illness,  because 
the  disease  is  seldom  infectious  before  the  outcrop  of  the  focal 
rash.  But  sometimes  they  lead  to  the  admission  of  a  patient, 
suffering  from  smallpox,  to  the  wards  of  a  hospital  or  infirm- 
ary for  other  diseases. 

Such  an  accident  is  most  likely  to  happen  when  the  ill- 
ness is  of  some  severity.  In  such  cases  the  symptoms 
commonly  prominent  are  a  high  temperature,  severe  frontal 
headache,  and  lumbar  pain ;  and  of  these  the  last  is  the  least 
constant.  The  range  of  temperature  is,  as  a  rule,  higher  than 
in  the  succeeding  fever  of  suppuration,  the  ascent  of  the  curve 
more  abrupt  but  its  height  less  sustained.  A  temperature  of 
103  is  commonly  exceeded;  104'  or  105"  is  frequently 
reached,  and  not  rarely  106''.  (See  Charts  l  to  v.)  Attending 
these  degrees  of  fever  there  is  often  a  good  deal  of  prostration, 
so  that  the  patient,  if  not  incapacitated,  is  unfit  or  disinclined  for 
exertion.  Most  complaint  is  made  of  the  headache,  but  some- 
times that  is  dwarfed  by  the  lumbar  pain.  From  a  good 
many  patients  the  existence  of  pain  in  the  back  is  elicited 
only  by  inquiry.  Others  complain  of  pain  not  so  much  in  the 
back  as  in  the  limbs,  or  "  all  over  " ;  occasionally  it  is  con- 
centrated in  the  chest  or  epigastrium. 

The  onset  of  illness  may  be  abrupt,  but  is  more  often 
gradual  The  symptoms  are  apt  to  come  on  in  the  night,  the 
patient  after  much  restlessness  finding  himself  with  a  head- 
ache and,  on  rising,  being  attacked  with  giddiness  and  nausea. 
There  is  likely  to  be  shivering,  but  rigors  are  exceptional 

The  acme  of  the  fever  and  of  the  symptoms  is  commonly 
reached  on  the  second  or  third  day  of  illness.  In  cases 
of  moderate  severity  the  duration  of  the  toxasmia  is  from  four 
to  six  days,  the  fever,  the  pains,  and  the  prostration  abating 
gradually  during  the  latter  part  of  that  time.  As  the 
outcrop  of  the  papular  rash  occurs  most  commonly  on   the 


60  THE    DIAGNOSIS    OF    SMALLPOX 

third  day  of  illness,  it  will  be  observed  that  the  outcrop  is  by 
no  means  coincident  with  the  disappearance  of  the  febrile 
symptoms  and  of  the  fever. 

Among  the  other  symptoms  of  the  toxaemia  may  be 
mentioned  vomiting;  this  is  a  common  symptom,  but  it 
occurs  only  in  a  minority  of  the  cases.  Excessive  salivation 
is  sometimes  noticed.  Sore  throat  is  generally  absent.  The 
tongue  is  thickly  furred  but  is  uncharacteristic.  It  is  im- 
portant to  bear  in  mind  that  the  eyes  are  generally  suffused 
and  may  be  faintly  injected.  This  trait  sometimes  gives  colour 
to  a  specious  mimicry  of  measles,  as  is  well  brought  out  in 
Plate  xciv. 

A  very  common  and  distressing  mental  symptom  is  sleep- 
lessness. Delirium  is  less  frequent,  and  is  most  apt  to  occur 
in  the  cases  of  children.  Mental  aberration  is  an  uncommon 
complication,  but  one  occasionally  attended  by  serious  conse- 
quences. It  occurs  independently  of  febrile  delirium,  is  not 
accompanied  by  conspicuous  pyrexia  and,  in  fact,  most  often 
occurs  in  cases  of  little  severity.  The  patient  may  be  maniacal 
or  melancholic.  He  has  delusions.  These  may  be  success- 
fully concealed,  and  the  first  warning  of  his  condition,  or  even 
of  his  illness,  may  be  an  attempt  at  suicide.*  These  mental 
symptoms  are  generally  of  brief  duration. 

In  some  cases  the  illness  is  of  still  greater  severity,  the 
prostration  alarming  and  the  other  symptoms  proportioned  to 
suit.  The  type  of  illness  then  approximates  to  that  more 
commonly  met  with  in  cases  of  hsemorrhagic  smallpox,  and 
will  be  dealt  with  in  a  later  chapter.  On  the  other  hand,  in 
the  milder  sorts  of  cases  the  symptoms  grade  downwards,  lose 
what  little  individuality  they  might  possess,  and  become  in- 
distinguishable from  those  of  many  trifling  disorders.  In 
some  cases  of  smallpox  inquiry  fails  to  elicit  the  history  of 
toxaemia  symptoms  of  any  description.  In  others  the  duration 
is  shortened ;  so  that,  sometimes,  when  the  focal  rash  is 
observed,  and  it  is  likely  to  be  insignificant  and  abortive,  the 

•  A  patient  came  under  the  writer's  observation,  whose  illness  was  unsus- 
pected until  he  was  under  arrest  for  attempting  suicide  by  leaping  into  the 
Thames  from  the  Tower  Bridge. 


THE    TOX.EMIC    FEVER  61 

precedent  malaise  has  been  forgotten,  and  the  patient  or  the 
doctor  fails  to  perceive  the  relation  between  t^he  two  events 
and  misses  the  significance  of  each. 

Incubation. — The  incubation-period  of  smallpox  is  gener- 
ally about  twelve  days  counting  to  the  onset  of  illness,  or 
fourteen  days  counting  to  the  outcrop  of  the  rash.  The 
length  of  this  period  varies  within  somewhat  narrow  limits, 
ranging  from  eleven  to  seventeen  days  reckoned  to  the 
date,  not  of  onset,  but  of  outcrop.  Periods  outside  those 
limits  are  exceptional  and  should  be  looked  upon  with  some 
suspicion. 

Though  it  is  illogical  to  do  so,  it  is  found  convenient  in 
practice  to  date  the  reckoning  of  the  incubation-period  to  the 
outcrop  rather  than  to  the  onset.  This  is  so,  partly  because 
with  the  milder  cases  the  symptoms  of  onset  are  apt  to  be 
vague  and  their  commencement  hard  to  define,  and  partly 
because,  when  the  outcrop  is  taken  as  the  determining  point, 
the  incubation-period  is  found  to  be  more  constant  in 
duration. 

Duration  of  the  pre-eruptive  period.— The  interval 
between  the  onset  and  the  outcrop  is  most  frequently  two 
days ;  that  is  to  say,  the  outcrop  occurs  generally  on  the  third 
day  of  illness.  But  the  duration  of  this  interval  is  very 
variable.  The  outcrop  may  occur  on  the  day  following  the 
onset,  or  may  be  coincident  with  it.  On  the  other  hand, 
the  interval  may  be  protracted.  It  is  very  common  for  the 
outcrop  to  occur  on  the  fourth  day  of  illness.  Sometimes  it 
occurs  on  the  fifth  day,  occasionally  on  the  sixth,  now  and 
again,  even  as  late  as  the  seventh.  (Chart  vl,  see  also  Charts 
1.  to  v.,  and  vii.) 

When  the  interval  is  much  prolonged,  the  onset  is  apt 
to  be  more  gradual  than  usual,  the  first  symptoms  being 
very  mild  and  vague.  The  fact,  that  the  duration  of  the  incu- 
bation is  more  inconstant  when  the  period  is  determined  by 
the  onset  than  when  it  is  determined  by  the  outcrop,  suggests 
that  when  the  pre  eruptive  period  is  protracted  the  interval 
between  onset  and  outcrop  may  have  been  prolonged  at  the 
expense  of  the  interval  between  exposure  and  onset     A  case 


62 


THE    DIAGNOSIS    OF    SMALLPOX 


may,  indeed,  present  evidence  of  the  force  of  this  explanation ; 
as,  for  instance,  when  a  patient  falling  ill  on  the  tenth  day 
after  exposure  nevertheless  develops  his  rash,  according  to 
custom,  on  the  fifteenth. 


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CUAKT    YI.  — DiSCKKTE    SMALLPOX    MITH    LoNG    PllE-Eiai'TlVE    PeKIOD. 


In  some  of  the  worst  cases,  especially  in  some  cases  of 
haimorrhagic  smallpox,  though  the  foregoing  explanation  may 
sometimes  hold  good,  a  protracted  interval  between  the  onset 
and  the  outcrop  is  due  rather  to  the  postponement  of  the  date 


THE    TOX.^MIC    FEVER  63 

of  the  latter  event.  In  Chapter  YI.  it  was  pointed  out  that  a 
toxaemia  of  exceptional  severity  has  sometimes  the  eftect  of 
hindering  the  evolution  of  the  lesions.  And  the  same  cause 
may  conduce  not  only  to  a  protracted  etiiorescence  of  the 
papules,  but  also  to  delay  in  their  first  outcrop. 

Inter-relation  of  the  toxaemic  and  suppurative  fevers. — 
There  is  imperfect  concordance  between  the  severity  of 
the  toxa3mic  symptoms  and  the  character  and  consequences 
of  the  focal  rash.  More  often  than  not,  a  scanty  focal  erup- 
tion is  preceded  by  mild  toxjcmic  symptoms,  and  a  plentiful 
eruption  by  a  severe  or  at  least  a  well-marked  toxaemia.  But 
exceptions  are  numerous  in  both  directions.  It  is  especially 
noticeable  that  a  severe  toxaemia  is  not  infrequently  followed 
by  a  rash  which,  if  not  insignificant  in  amount,  at  any  rate 
induces  an  insignificant  suppurative  fever.  (Chart  vii., 
see  also  Charts  iv.  and  v.,  p.  37  and  p.  38.) 

Such  a  fortunate  concurrence  of  events  is  generally  due 
to  the  partial  disappearance  of  a  vaccinal  immunity.  This 
artificial  immunity  not  only  has  the  effect  of  modifying  the 
numerical  severity  of  the  focal  rash  and  the  suppuration  of  its 
lesions  but,  in  addition,  mitigates  or  abolishes  the  toxaemia. 
As,  with  the  lapse  of  years,  the  two  first  faculties  become 
gradually  attenuated,  so  also  does  the  last.  But  the  pro- 
cess of  attrition  is  not  relatively  uniform.  The  faculty 
retained  longest,  it  has  been  pointed  out,  is  that  of  preventing 
or  modifying  the  suppuration  of  the  lesions.  That  which  is 
lost  first  is  immunity  to  the  toxaemia.  It  follows  that  vaccin- 
ated persons  may  have  lost  their  artificial  faculty  of  resisting 
the  action  of  the  toxins  of  the  septicaemia,  and  may  suffer  a 
toxaemic  fever  mild  or  severe  as  determined  by  nature  alone, 
and  yet  may  exhibit  a  focal  rash  which,  if  not  insignificant 
numerically,  is  insignificant  in  its  effects. 

Vai'iola  sine  eruj)tione. — On  this  account  it  arises  that, 
among  the  vaccinated,  cases  are  to  be  encountered  in  which 
the  focal  rash  is  so  disproportionate  to  the  severity  of  the 
toxaemia  that  the  nature  of  the  disease  is  mistaken,  because 
the  observer,  occupied  by  the  toxaemic  symptoms,  disregards 
the  rash  which   they  obscure.     Indeed,   it   is  plain  that   a 


64 


THE    DIAGNOSIS    OF    SMALLPOX 


loe- 

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98» 
97» 

Day  of      ) 

DISEASE        ) 
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Chart  vii.— Discrete  SiaALLrox  without  Secondary  Fever. 


patient  might  develop  a  variolous  toxsBmia  which  would  never 
be  followed  by  efflorescence.  {See  Chart  viii.)  Unquestion- 
ably such  cases  sometimes  occur,  but  it  is  generally  safe  to 
neglect  them  since  it  seldom  happens  that  the  toxsemia  is 
infectious. 


THE    TOXiEMIC    FEVER 


65 


106- 
105° 

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i 

^" 

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102" 
IOI» 
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Chart  viii. — Variola  Sine  Ehuptioxe  after  Successful  Vaccinatioij 
ON  THE  Eighth  Day  after  Exfosvue. 


CHAPTER  X 

TOXiEMIC    RASHES 

TnfiSE  rashes,  coming  with  the  symptoms  of  a  specific  fever, 
tempt  one  to  suspect  or  proclaim  the  presence  of  a  commoner 
exanthem.  The  most  to  be  expected  from  a  knowledge  of 
them  is  sometimes  a  happy  suspension  of  judgment. 

The  rashes  of  the  variolous  toxsemia,  or,  at  any  rate,  one 
kind  of  them,  are  the  analogues  of  the  erythemata  of  scarlet 
fever  and  measles,  but,  unlike  those  eruptions,  they  are  seen 
only  in  a  minority  of  the  cases.  The  frequency  of  occurrence 
of  toxsemic  rashes  varies  with  the  epidemic,  but,  generally,  a 
rash  is  not  developed  in  more  than  one  case  out  of  ten.  The 
rash  may  appear  at  any  time  during  the  early  and  middle 
parts  of  the  toxaemic  fever,  and  often  does  not  come  until 
after  the  outcrop  of  the  focal  rash.  The  commonest  time  is 
on  the  second  or  third  day  of  illness. 

There  are  two  varieties  of  toxsemic  rashes,  the  petechial 
or  purpuric,  and  the  erythematous.  This  distinction  is  well- 
marked  clinically  and  expresses  more  thaxi  a  superficial  differ- 
ence. The  two  varieties  are  characteristic  of  different  types 
of  disease.  The  purpuric  rash  is  an  indication  of  a  severe 
toxaemia;  not  necessarily  of  a  serious  attack  of  smallpox, 
because  a  severe  toxaemia  may  or  may  not  be  followed  by  a 
severe  focal  rash  and  suppurative  fever.  (See  Chart  v.,  p.  38.) 
Though  a  severe,  or  even  a  fatal,  toxaemia  by  no  means  neces- 
sarily induces  such  a  rash,  it  follows  that  it  is  relatively  more 
frequent  in  cases  of  hoemorrhagic  smallpox.  Yet  it  is  fre- 
quently met  with,  also,  in  the  less  serious  forms  of  the  disease 
which  do  not  themselves  endanger  life  but  cause,  at  the  least, 
a  noticeable  illness. 

The  rose  rashes,  on  the  other  hand,  have  no  constant 
relation  to  the  character  of  the  toxaemia.     For  though  the 

66 


TOX.EMIC    RASHES  67 

toxemic  fever  is  generally  mild  among  those  who  exhibit 
such  rashes,  it  may  yet  be  moderately  severe.  They  are  df  good 
omen,  because  it  happens  nearly  always  that  the  subjects  of 
them  have  either  a  discrete  or  a  modilied  focal  eruption.  They 
are,  therefore,  seen  mostly  among  the  vaccinated.  What  they 
indicate  is  that  the  patient  possesses  or  retains  a  considerable 
amount  of  natural  or  acquired  immunit}^  The  rose  rashes, 
indeed,  may  be  thought  of  as  antitoxic  rashes.  Nevertheless, 
it  will  be  seen  in  another  chapter  that  a  very  similar  rash 
to  some  of  these  occurs  in  certain  cases  of  hemorrhagic  small- 
pox, but  heralds  death  instead  of  recovery.  (Chapter  XIII., 
p.  98.) 

Purpuric  or  petechial  rash. — The  development  of  a  few 
petechioe  is  a  common  symptom  of  the  toxajmic  fever.  In 
cases  of  hemorrhagic  smallpox,  indeed,  this  symptom  is  some- 
times conspicuous.  Yet  such  an  exhibition  of  petechise,  for- 
tuitousl}'  arranged,  does  not  constitute  the  purpuric  rash.  It 
is  in  the  aggregation  of  petechise  that  this  rash  is  peculiar, 
and  especially  in  their  method  of  arrangement. 

The  essence  of  the  rash  is  that  it  affects  the  great  flexures 
of  the  trunk,  parts  which  seem  ever  to  show  a  special  tendency 
to  blood-stasis  in  the  capillaries  of  the  skin  and  to  capillary 
hemorrhage.  Probably  in  all  cases  the  rash  in  its  earliest  stage 
is  a  simple  erythema.  When  it  is  extensive  in  distribution 
and  developed  conspicuously,  it  consists  of  a  dusky  red  erythe- 
matous background  which  is  stippled  with  innumerable  small 
haeniorrhagic  extravasations  resembling  flea-bites.  The  vivid- 
ness and  depth  of  tint  of  the  erythema  varies  from  case  to  case 
and  with  the  age  of  the  rash.  The  petechie,  being  more  persist- 
ent, may  be  seen  for  several  days  after  the  erythema  has 
faded.  The  erythema,  indeed,  in  many  cases  is  very  fugitive, 
and  no  more  Ls  to  be  noticed  than  a  mere  grouping  of  petechise 
on  the  areas  affected. 

The  regions  most  favoured  are  the  parts  near  the  groins, 
and  to  that  neighbourhood  the  rash  often  is  limited.  Its 
lower  boundaries  in  many  cases  are  curiously  distinct, 
running  slantwise  towards  each  other  across  the  thighs  an 
inch    or    two    below    and    parallel    to    Poupart's    ligaments. 


68  THE    DIAGNOSIS    OF    SMALLPOX 

(Plate  Lxxv.)  The  rash  seldom  extends  below  the  upper 
third  of  the  thigh,  even  when  developed  most  extensively 
and  profusely.  The  upper  limits  are  never  so  distinct. 
When  the  rash  is  pronounced  it  reaches  upwards  over  the 
flanks  and  the  abdomen  to  the  armpits  and  the  chest,  being 
more  vivid  and  closer  set  with  petechise  on  the  sides  of  the 
body  than  in  front.  When  the  rash  comes  into  the  armpit, 
it  is  apt  also  to  stretch  a  little  way  down  the  inner  side  of 
the  arm ;  it  may  even  encircle  the  arm  below  the  point  of  the 
shoulder,  the  arm  passing  through  the  cincture  as  through 
the  sleeve  of  a  bodice.  Looked  at  from  the  front,  the  rash 
seems  to  clothe  the  patient  like  a  vest  and  bathing-drawers. 
On  the  back  the  rash  generally  is  undeveloped.  In  some 
cases,  however,  a  band,  sometimes  narrow,  sometimes  broad, 
stretches  like  an  apron-string  across  the  loins  (the  flexure  of 
the  back)  and  connects  the  major  part  of  the  rash  from  flank 
to  flank. 

A  rash  so  widespread  is  most  pronounced  in  the  recesses 
of  the  flexures,  the  groins,  the  hypogastrium,  and  the  arm- 
pits (Plates  Lxxvi,  and  lxxix.,  Fig.  1) ;  and  is  developed  most 
scantily  on  the  chest  and  epigastrium.  Yet  it  must  not  be 
supposed  that  the  cases  are  numerous  in  which  an  area  so 
extensive  is  covered.  When  the  confines  are  narrowed,  the 
rash  comes  only  in  the  most  favoured  parts.  In  most  cases 
it  comes  in  the  groins  alone,  or  in  the  groins  and  hypogas- 
trium, or  in  the  groins  and  armpits.  Less  frequently  it  comes 
in  the  armpits  alone.  As  a  rule  the  rash  is  bilaterally  sym- 
metrical, but  sometimes  it  is  more  pronounced  on  one  side  of 
the  body  than  on  the  other.  Occasionally  it  is  unilateral,  but 
in  such  cases  it  is  never  very  abundantly  developed. 

The  limits  of  distribution  which  have  been  defined  apply 
more  particularly  to  the  purpuric  elements  of  the  rash. 
When  an  erythematous  groundwork  is  present,  the  same 
limits  apply,  in  general,  to  that  also.  Nevertheless,  if  the 
rash  be  very  profuse,  the  erythema  may  overflow  the  normal 
confines  of  the  rash  and  appear  upon  the  back  and  limbs. 
In  such  case,  the  overflow  which  extends  beyond  the  natural 
limits  of  the  rash  will  be  less  vivid  in  colour  and  will  not 


TOXEMIC    RASHES  69 

show  the  wonted  tendency  to  blood-stasis  or  to  the  develop- 
ment of  petechial  elements. 

Effect  on  the  incidence. — A  peculiarity  of  the  purpuric 
rash  is  that  it  has  a  tendency  to  shield  from  the  invasion 
of  the  focal  lesions  those  parts  of  the  skin  which  it  occupies. 
The  evidence  on  which  this  conclusion  is  based  is  vitiated  by 
the  consideration  that  the  favourite  situations  of  the  purpuric 
rash — the  great  flexures  and  the  abdomen — are  those  parts, 
precisely,  which  the  focal  rash  habitually  shuns.  Yet,  after 
giving  due  weight  to  that  circumstance,  the  fact  remains  that, 
when  the  purpuric  rash  is  vivid  and  the  focal  rash  abundant, 
the  immunity  to  the  latter  of  the  area  covered  by  the 
former  is  occasionally  demonstrated  with  quite  extraordinary 
distinctness. 

The  explanation  of  this  peculiar  effect  is  easy  to  understand.  Pro- 
nounced purpuric  ra.shes  are  developed,  commonly,  before  the  outcrop  of 
the  focal  rash  ;  and,  if  the  capillary  circulation  in  a  certain  part  of  the 
skin  has  become  blocked  before  the  precipitation  of  the  agent  which 
causes  the  focal  lesion,  the  subsequent  precipitation  of  that  tigent  will 
thereby  be  prevented.     {See  p.  9.) 

It  may  be  mentioned  that  in  rare  cases  the  opposite  condition 
occurs  ;  that  is  to  say,  on  that  part  of  the  surface  where  the  purpuric 
rash  is  most  vivid  (generally  in  the  groins)  the  focal  rash  becomes 
developed  with  unwonted  profuseness.  It  is  impossible  to  determine 
what  circumstances  unite  to  secure  such  a  result ;  but  probably,  during 
the  changes  in  the  capillary  blood-current  consequent  upon  the 
incidence  of  the  purpuric  rash,  changes  which  range  from  the  normal 
condition  of  the  circulation  down  to  complete  stasis,  a  favourable, 
though  transient,  state  of  flow  happens  to  occur  at  a  particular  time 
when  the  active  agent  in  the  blood  is  ripe  for  precipitation. 

Diagnosis. — From  the  peculiar  character  and  disposition  of 
this  rash  a  case  of  smallpox  may  be  recognised,  sometimes, 
even  before  the  outcrop  of  the  papules ;  or,  again,  the  rash 
may  be  a  confirmative  element  in  the  diagnosis  after  the 
focal  eruption  has  appeared.  Unfortunately  the  purpuric 
rash  may  be  mistaken  for  the  rash  of  scarlet  fever.  In  severe 
cases  of  that  disease  the  erythema  exhibits,  occasionally,  on 
the  fore  part  of  the  trunk  a  character  similar  to  that  of  the 
variolous  rash  ;  that  is  to  say,  it  is  dusky  in  tint,  sluggish  in 


70  THE    DIAGNOSIS    OF    SMALLPOX 

reaction,  and  flecked  with  petechije.  The  distinction  between 
the  two  Ues  in  the  pecuHar  dehmitation  of  the  variolous  rash, 
in  its  sharp  line  of  demarcation  on  the  thighs,  in  its  greater 
purpuric  tendency,  and  in  the  absence  of  the  distinctive  signs 
of  scarlet  fever. 

Rose  rashes. — These  erythernata  are  deficient  of  the 
fixed  character  and  individuality  of  distribution  of  the 
purpuric  rash.  Of  one  kind  the  seat  of  election  is  the 
trunk  of  the  body  (Plate  lxxvii.),  to  which  part  the  invasion 
may  be  limited  ;  but  in  other  cases  the  rash  extends  on  to  the 
limbs.  There  is  a  second  type  which  has  a  special  preference 
for  the  limbs,  particularly  for  their  distal  ends  and  extensor 
surfaces.  (Plate  lxxviii.)  Neither  kind  of  rash  has  any  special 
affinity  for  the  face,  though  they  may  invade  it.  The  presence 
of  one  of  these  rashes  is  not  necessarily  a  bar  to  the  develop- 
ment of  a  purpuric  rash  in  the  flexures,  but  the  two  sorts  do 
not  often  come  together. 

When  the  rose  rash  is  of  the  more  general  distribution  it 
consists  of  a  bright  erythema,  which  causes  no  thickening  of 
the  skin,  has  little  or  no  tendency  to  cause  blood-staining,  and 
is  often  fugitive.  The  erythema  may  be  uniform  and  un- 
broken, but  frequently  it  is  composite  or  particulate.  In 
the  latter  case  it  may  be  punctate,  like  the  rash  of  scarlet 
fever,  or  of  coarser  texture,  more  nearly  resembling  that  of 
measles.  Sometimes  the  erythema  has  a  still  more  broken 
character,  being  interrupted  by  small  or  large  areas  of 
white  skin  Avhich  give  the  rash  an  irregular  splash-like 
character. 

The  other  form  of  rose  rash  is  limited  in  most  cases  to 
the  limbs,  in  many  cases  to  the  arms,  and  occasionally  to  the 
legs  only.  In  typical  cases  the  rash  comes  up  about  half-way 
on  to  the  upper  arms,  and  on  the  legs  extends  above  the 
knees.  It  is  made  up  of  red  discs  with  a  well-defined  edge, 
in  size  and  colour  like  the  vesicular  areola.  (Plates  lxxix., 
Fig.  2,  and  lxxx.)  Below,  on  the  backs  of  the  hands, 
wrists  and  forearms,  or  on  the  shins  and  the  dorsa  of  the 
feet,  the  spots  run  together  to  make  a  sheet  of  even  redness. 
Where  the  rash  creeps  round  on  to  the  flexor  surface  of  the 


TOX.EMIC    RASHES  71 

limb,  and  higher  up  towards  the  elbow  or  the  knee,  the  rash 
thins  out  and  the  elements  become  distinct.  This  erythema 
is  commonly  darker  in  tint  than  the  rose  rash  previously 
described,  and  it  is  less  labile.  It  is  apt,  therefore,  to  be 
somewhat  more  persistent,  and,  when  it  fades,  to  leave  a 
slight  yellow  staining  of  the  skin ;  but  it  does  not  become 
purpuric. 

In  some  cases  the  rash  last  described  has  a  wider  dis- 
tribution, covers  all  the  limbs,  and  invades  the  trunk.  (Plates 
Lxxxi.  and  lxxxii.)  Since,  therefore,  the  one  kind  of  rose 
rash  may  extend  from  the  trunk  and  cover  the  limbs,  and 
the  other  may  spread  from  the  limbs  over  the  body,  it  is 
obvious  that  in  some  cases  the  distribution  will  be  indiiferent. 
In  most  cases  it  is  not  difficult,  by  observing  the  seat  of 
election  of  the  rash  and  the  character  of  its  elements,  to 
determine  to  which  group  it  belongs.  But  the  discrimi- 
nation is  superfluous,  since  both  have  the  same  clinical 
significance. 

Diagnosis. — These  rashes  are  a  prolific  source  of  confusion. 
Occasionally  they  are  attributed  to  scarlet  fever,  but  much 
more  often  to  measles.  The  kind  last  described,  which  prefers 
the  limbs,  should  be  distinsruished  from  the  rash  of  measles 
without  much  difficulty,  for  their  affinities  of  distribution  are 
opposite.  The  other  kinds,  also,  have  some  points  of  distinction 
from  measles,  but  these  would  be  of  more  value  were  not 
the  temptation  to  ignore  them  so  often  overwhelming.  An 
interrupted  erythema,  constitutional  symptoms  suggestive  of 
a  specific  fever  and,  as  likely  as  not,  suffused  eyes  or  faintly 
mjected  conjunctivae, — with  such  a  conjunction  of  symptoms 
there  is  a  temptation  to  ignore  a  discrepancy  in  the  anatomy 
of  the  rash  and  in  its  distribution.  The  chief  diflFerence  in  distri- 
bution is  that  the  variolous  rash  does  not,  generally,  affect  the 
face ;  or,  if  the  face  is  affected,  the  rash  shows  no  discontinuity 
of  surface  there,  and  no  special  choice  for  the  skin  behind  the 
ears,  and  over  the  temples,  and  among  the  hair-roots.  The 
variolous  erythema  is  apt  to  be  irregular  in  distribution, 
irregular  in  the  profuseness  of  its  development  and  in  its 
depth  of  tint,  and  lacking  in  uniformity  of  composition.     It 


72  THE    DIAGNOSIS    OF    SMALLPOX 

differs  in  elementary  character  from  the  measles  rash,  if  not 
on  all  parts,  at  least  on  some ;  the  erythema  being  too  fine  in 
texture,  or  too  coarse,  or  too  patchy,  and  the  skin  affected  by 
it  not  being  thickened  or  raised. 

Confusion  with  scarlet  fever  is  less  frequent,  though  the 
resemblance  of  the  rashes  may  be  closer.  The  distinction,  in 
fact,  in  most  cases  is  easy  to  make  by  an  examination  of  the 
mouth  and  throat  and  glands. 


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PLATE   LXXVII. 


A  toxsemic  variolous  erythema,  scarlatiniform  in  type  and  generalised  in  distribu- 
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PLATE   LXXVIII. 


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CHAPTER    XI 

HiEMORRHAGIC    SYMPTOMS 

The  key  to  a  clear  conception  of  this  phase  of  the  disease  is 
to  remember  that  hemorrhage  from  smallpox  is  not  synony- 
mous with  hsemorrhagic  smallpox. 

A  patient  may  be  said  to  suffer  from  toxic  or  hsemor- 
rhagic  smallpox  when  his  life  is  menaced  by  the  toxaemia.* 
An  analogy  is  furnished  by  scarlet  fever.  Cases  of  that  disease 
are  encountered,  which  are  dominated  by  the  constitutional 
rather  than  by  the  local  symptoms.  Such  cases  are  called 
toxic  cases.  They  are  signalised  by  a  r|ish  which  shows  a 
marked  aptitude  for  blood-staining,  and  they  go  on  rapidly 
to  a  fatal  issue.  They  are  in  contrast  with  cases  in  which 
the  angina  is  pronounced,  and  death,  if  it  occurs,  follows 
from  septic  absorption.  Those  two  groups  are  analogues  of 
hsemorrhagic  and  confluent  smallpox.  Hsemorrhagic  small- 
pox is  toxic  smallpox,  and  in  this  volume  the  terms  are  used 
indifferently. 

In  separating  for  convenience  of  description  a  group  of 
cases  which  conform  to  an  imaginary  type,  it  must  be 
remembered  that  the  practice  is  arbitrary.  Haemorrhagic 
or  toxic  smallpox  has  no  peculiarity  which  is  essential.  No 
fixed  line  separates  the  toxic  from  the  less  serious  cases,  but 
there  is  a  gradation  from  the  milder  cases  up  to  those  in 
which  death  descends  with  relentless  rapidity.  It  follows 
that  symptoms  of  haemorrhage  cannot  be  regarded,  as  the 
name  haemorrhagic  smallpox  would  seem  to  imply,  as  the 

*  It  is  sometimes  convenient,  foi"  statistical  purposes  for  example,  to  use  a 
definition  which  is  more  exact.  It  is  then,  perhaps,  best,  in  the  present  state  of 
our  therapeutics,  to  restrict  the  terms  to  those  cases  which  are  fatal  from  the 
toxaemia,  or  from  some  condition  (such  as  oedema  of  the  lungs)  which  the 
toxaemia  has  induced. 

73 


74  THE   DIAGNOSIS    OF    SMALLPOX 

hall-mark  of  a  peculiar  type  of  disease ;  and  it  will  be  under- 
stood that  this  chapter  is  devoted  to  the  description,  not  of  a 
type  of  disease,  but  of  a  group  of  symptoms. 

Hsemorrhagic  symptoms  are  due,  doubtless,  to  the  circu- 
lation of  a  specific  poison  or  toxin.  The  sequence  is  not 
peculiar  to  smallpox;  it  occurs  in  cases  of  hfemorrhagic 
diphtheria,  of  toxic  scarlet  fever,  of  pneumonic  plague,  and 
from  some  kinds  of  snake-bite  poisoning.  The  toxins  inci- 
dental to  those  different  maladies  differ  in  their  ability  to 
cause  haemorrhage ;  that  of  smallpox  is  peculiarly  apt,  and 
death  from  the  variolous  toxaemia  is  almost  ahvays  preceded 
by  haemorrhagic  manifestations. 

The  haimorrhage  itself  is  seldom  dangerous.  It  is  im- 
portant as  an  expression  of  the  operation  of  the  toxin.  Yet, 
from  case  to  case,  the  toxin  operates  with  unequal  effects. 
Its  precise  action  will  depend,  not  only  upon  the  dose,  but 
also  upon  the  patient  and  his  vital  weaknesses.  In  one  case 
the  bleeding  will  be  chiefly  from  the  air-passages,  in  a  second 
there  will  be  haematuria,  in  a  third  cutaneous  haemorrhage 
only.  Moreover,  of  two  patients  equally  severely  poisoned, 
in  one  case  the  haemorrhagic  symptoms  will  be  masked,  in 
the  other  they  will  be  pronounced.  The  significance  of  the 
different  haemorrhagic  symptoms  will  depend,  therefore,  not 
only  upon  the  kind  and  degree  of  haemorrhage,  but  equally 
upon  the  other  symptoms  with  which  they  are  associated. 
Many  patients,  not  desperately  ill,  exhibit  haemorrhagic 
symptoms  of  a  sort ;  and,  indeed,  in  almost  all  cases  of 
smallpox  there  can  be  discerned  the  trail  of  the  special 
faculty  to  bleed. 

Post-toxsemic  haemorrhage.  —  The  extravasations  are 
secondary,  it  may  be  supposed,  to  some  damage  suffered  by 
the  vascular  endothelium  or  to  some  injurious  action  of  the 
toxin  on  the  vascular  mechanism.  Such  damage  can  be 
effected  only  while  the  toxin  is  circulating  in  the  blood ;  that 
is  to  say,  during  the  toxaemic  fever.  Yet  the  effect  of  the 
damage,  the  liabihty  to  haemorrhage,  may  remain  with  the 
patient  even  after  the  elimination  of  the  toxin  has  been  fulfilled. 
Patients,  therefore,  who  have  passed   through  the  toxtemia 


H.EMORRHAGIC    SYMPTOMS  75 

and  entered  upon  the  separate  hazards  of  the  secondary  fever, 
may  still  exhibit  signs  of  the  haemorrhagic  tendency.  A  slight 
injury,  which  would  be  innocuous  in  health,  may  cause 
a  blood-effusion  in  a  patient  whose  vessels  are  already 
weakened  by  the  disease.  Thus  patients  with  smallpox  are 
exceptionally  liable  to  bruises,  even  during  the  period  of 
suppuration. 

Another  sign  is  so  common  that  it  may  be  observed  in 
almost  every  case.  The  focal  lesion,  it  will  be  seen  presently, 
is  an  injury  so  potent  that  in  the  severer  cases  it  may 
determine  a  bloody  extravasation  about  itself  long  before  its 
maturity.  When  the  patient  is  less  severely  poisoned,  a 
premature  lesion  does  not  have  that  effect ;  but  as  the  lesion 
ages,  and  grows,  and  suppurates,  and  destroys  the  tissue  about 
it,  the  stimulus  gathers  force ;  and  at  last,  even  in  the  milder 
cases,  excites  an  extrusion  of  hsemocytes  from  the  vessels, 
which  may  be  unnoticed  at  the  time,  but  leaves  its  record 
in  the  pigmented  area  which  surrounds  the  scar.  (Plates 
Lxxi.,  Fig.  2,  and  lxxiii..  Fig.  1.) 

In  some  cases  the  extravasation  is  obvious  before  the 
pustule  has  become  encrusted.  It  is  not  uncommon  in  cases 
of  confluent  smallpox,  more  especially  on  the  arms  and  legs 
where  the  stimulus  of  the  lesion  is  supplemented  by  the 
movements  of  the  limb,  to  see  some  of  the  pustules  with 
blood-stained  contents.  (Plates  lxxxiii.  and  lxxxiv.. 
Fig.  1.)  Occasionally  these  hjemorrhagic  pustules  are  dis- 
played, even  in  cases  of  discrete  smallpox,  over  a  considerable 
area  of  the  body. 

Yet  all  these  tardy  evidences  of  the  tendency  to  bleed  are 
wholly  devoid  of  significance.  They  are  but  the  foot-prints 
of  an  illness  which  has  passed. 

Toxaemic  haemorrhage. — Other  factors  being  equal,  the 
greater  the  dose  of  the  toxin,  the  earlier  and  the  more  readily 
will  become  manifest  its  capacity  to  provoke  haemorrhage. 
Therefore  a  haemorrhagic  symptom,  developed  during  the 
course  of  the  toxaemic  fever,  assumes  at  once  a  certain 
clinical  significance. 

Yet  many  of  these  manifestations  are  not  of  serious  omen. 


76  THE    DIAGNOSIS    OF    SMALLPOX 

It  is  a  general  rule  that  bleeding  from  internal  structures  or 
surfaces  is  more  serious  than  external  extravasations.  Some 
kinds  of  cutaneous  haemorrhage  are,  in  fact,  so  common  that 
they  may  be  regarded  as  ordinary  symptoms  of  the  toxaemia. 
One  such  symptom  is  the  exhibition  of  the  purpuric  or 
petechial  rash,  which  was  described  in  Chapter  X.  and  will 
be  referred  to  also  in  a  later  chapter.  Petechise,  again,  not 
specially  grouped,  but  scattered  fortuitously  and  often 
sparsely  over  the  surface,  are  apt  to  appear  on  the  skin  of 
the  trunk  and  upper  parts  of  the  limbs  with  all  the  severer 
sorts  of  toxaemia,  especially  in  the  cases  of  children. 

A  graver,  but  not  necessarily  a  fatal  sign  is  the  develop- 
ment of  small  round  or  oval  extravasations,  clear-cut  and 
counter-sunk  (Plate  lxxxiv..  Fig.  2.)  In  this  instance,  also, 
children  are  the  favourite  subjects.  These  spots  are  seldom 
bigger  than  a  split  pea.  Their  colour  ranges  from  violet  to 
black,  according  to  the  depth  of  tissue  occupied.  L"''sually 
they  are  sparingly  developed.  They  choose  the  parts 
most  apt  to  display  petechiae,  with  which  they  are  often 
associated. 

Of  more  serious  omen  still  are  cutaneous  extravasations 
occurring  in  streaks  and  patches.  Such  blotches  are  irregular 
in  outline,  and  inconstant  in  depth  of  tint.  They  may  appear 
on  any  part  of  the  skin,  and  may  attain  a  considerable  size. 
If,  in  a  case  of  toxic  smallpox,  an  erythematous  rash'  is 
developed,  it  very  readily  becomes  streaked  or  mottled  by 
such  areas  of  discoloration.  Yet  a  toxsemic  rash,  present- 
ing such  a  character,  is  not  necessarily  of  the  most  serious 
significance  unless  the  colour  is  very  dark,  that  is  to  say,  deep 
purple  or  black.  {See  also  Chapter  XIII.,  p.  98.)  Hemor- 
rhage of  this  sort  is  to  be  regarded  the  more  seriously  when 
not  excited  by  a  coincident  erythema. 

Toxic  smallpox  causes  the  blood  to  coagulate  imperfectly. 
Hence  a  scratch,  or  a  trifling  abrasion  of  the  skin,  is  very  apt 
to  be  marked  by  a  continuous  or  interrupted  oozing  of  blood 
from  the  broken  surface. 

Extravasations  about  the  vesicles  or  papules  are  among 
the  most  frequent  of  haemorrhagic  symptoms. 


HiEMORRHAGIC    SYMPTOMS  77 

The  areola  is  more  prone  to  be  affected  than  the  lesion 
itself.  Sometimes  it  is  only  to  be  observed  that  the  colour 
of  the  areola  is  immobile ;  and  when  it  has  faded,  that  it 
has  left  its  record  in  blood-pigment.  But  when  the  vessels 
are  more  impaired,  the  areola  acquires  a  violet  or  purple  tint 
from  the  excessive  effusion  of  blood.  (Plate  lxxxv.)  Blood- 
stained areolcB  niay  be  developed  over  the  greater  part  of 
the  cutaneous  surface,  but  are  seen  most  often  on  those 
parts  of  the  body,  such  as  the  shins,  where  the  circulation 
is  slow. 

Either  alone,  or  in  conjunction  with  the  staining  of  the 
areola,  an  extravasation  may  occur  into  the  vesicle  itself;  and 
the  latter  is  the  more  serious  sign  of  the  two.  The  effusion 
may  be  directly  into  the  cavity  of  the  vesicle,  which  turns 
black  from  the  blood  which  distends  it.  But  that  event  is 
relatively  uncommon,  and  at  the  most  but  few  of  the  vesicles 
are  so  affected.  Generally  the  effusion  takes  place  into  the 
tissue  at  the  base  of  the  vesicle.  The  colour  and  ocular 
definition  of  the  effused  blood  are  then  obscured  by  the 
superjacent  lesion;  and  unless  the  extravasation  is  very  pro- 
nounced, it  looks  indistinct,  as  though  seen  through  a  bluish 
haze,  like  a  stained  object  out  of  focus  in  the  microscope. 
(Plate  LXXXV.,  Fig.  2.)  These  subvesicular  effusions  are  among 
the  commonest  of  the  haimorrhagic  signs  of  the  toxaemia.  In 
some  cases — and  in  many  of  these  the  toxasmic  fever  is  not 
especially  serious — only  a  few  vesicles  are  affected  ;  but  at  the 
worst  the  extravasations  are  very  prominent  and  cover  the 
patient  from  head  to  foot,  obscuring  the  whole  character 
of  the  rash.  It  must  be  remembered  that  the  number 
and  prominence  of  these  extravasations  are  not  sure  guides 
to  the  probable  issue,  and  that  in  many  cases  of  toxic 
smallpox,  fatal  in  the  vesicular  stage,  the  sign  is  relatively 
inconspicuous. 

The  papules  are  not  so  liable  as  the  vesicles  to  become  the 
foci  of  hsemorrhagic  extravasation.  The  papule  and  the 
papular  areola  sometimes  become  blood-stained ;  less  fre- 
quently, the  papule  becomes  capped  with  blood.  (Plate 
xci.) 


78  THE    DIAGNOSIS    OF    SMALLPOX 

The  significance  of  a  hasmorrhagic  effusion  varies  in  pro- 
portion as  it  is  spontaneous,  and  not  accidental  or  factitious. 
Subcutaneous  hsemorrhage  is,  therefore,  not  necessarily  of 
serious  omen.  Not  infrequently  a  bruise  can  be  traced  to 
some  injury,  and  all  patients  with  smallpox  bruise  easily. 
But  the  significance  of  the  bruise  increases  with  the  dispro- 
portion between  cause  and  effect ;  and  multiple  bruise-like 
effusions  are  sometimes  the  most  prominent  feature  of  a  case 
of  toxic  smallpox.  In  many  cases  subcutaneous  extravasa- 
tions occur  which  are  not  so  pronounced  as  to  cause  dis- 
coloration of  the  skin ;  but  they  can  be  discerned  beneath 
the  surface  as  indistinct  vein-like  markings. 

A  favourite  situation  for  effusion  of  blood  is  the  orbit. 
The  effusion  may  even  be  so  extensive  as  to  cause  distinct 
proptosis  of  the  eyeball.  Still  more  common  is  extravasation 
into  the  ocular  conjunctiva.  The  efiusion  assumes  a  tri- 
angular shape,  the  base  of  the  triangle  13'^ing  against  the 
cornea.  Conjunctival  haemorrhage  may  be  one-sided  or 
double.  It  may  be  developed  both  on  the  inner  and  on  the 
outer  side  of  the  cornea,  and  in  the  worst  cases  the  whole  of 
the  conjunctiva  becomes  filled  with  blood.  Conjunctival 
haemorrhage,  unless  very  pronounced,  is  not  to  be  regarded 
with  despondence.  It  is  among  the  least  serious  of  the 
haemorrhagic  symptoms. 

While  haemorrhage  from  within  is,  in  the  main,  to  be 
regarded  more  seriously  than  extravasations  on  the  surface, 
the  evidence  must  still  be  used  with  discrimination.  Perhaps 
the  most  common  of  these  symptoms  is  uterine  haemorrhage. 
But  all  forms  of  the  toxa3mia  have  a  tendency  to  induce 
prematurely  the  menstrual  flow  ;  and  if  the  patient  is  preg- 
nant, a  toxaemia  of  even  moderate  severity  is  capable  of 
causing  abortion.  It  is  not  surprising,  therefore,  that 
when  women  get  toxic  smallpox,  repeated  or  continuous 
uterine  haemorrhage  should  be  the  rule.  Again,  epistaxis 
is  a  common  symptom  of  toxic  smallpox.  But  when 
the  patient  is  subject  to  epistaxis,  or  is  a  child,  the 
symptom  is  to  be  regarded  differently  from  repeated  or 
continuous  bleeding  from  the  nose  when  the  patient  is  a 


HiEMORRHAGIC    SYMPTOMS  79 

stranger  to  that  symptom.  Similarly,  a  little  oozing  from 
the  gums  need  not  be  taken  very  seriously ;  but  a  dark  bloody 
extravasation  into  the  mucous  membrane  of  the  fauces,  the 
palate,  and  the  root  of  the  tongue,  is  a  common  and  character- 
istic symptom  in  toxic  cases. 

With  rare  exceptions,  only  in  toxic  cases  do  other  kinds 
of  internal  haemorrhage  become  prominent.  Hasmoptysis  is 
common ;  generally  it  comes  on  late  in  the  toxiemia,  and  is  a 
sign  of  congestion  or  oedema  of  the  lungs.  Haemateraesis 
occurs  with  frequency  in  cases  in  which  it  cannot  be  ascribed 
to  the  swallowing  of  blood  poured  out  from  .the  nose,  or 
throat,  or  lungs.  Melaena  is  less  common,  but  by  no  means 
rare.  A  symptom,  one  of  the  most  frequent  of  all,  is  haema- 
turia.  In  this  connection  the  word  does  not  imply  merely 
the  passage  of  "  smoky  "  urine,  but  the  voiding  of  fluid  of  the 
colour  of  port  wine. 

Prognosis.  —  Extravasation  into  the  faucial  mucous 
membrane,  severe  or  continuous  haemoptysis,  hsematemesis, 
haematuria,  continuous  epistaxis,  multiple  spontaneous 
bruises,  purple  cutaneous  extravasations,  numerous  extravasa- 
tions about  the  focal  lesions, — when  there  is  a  combination  of 
some  of  these  symptoms,  the  patient  very  seldom  recovers. 
But  the  significance  of  any  one  of  them  is  much  reduced  if  it 
stands  alone,  and  it  is  seldom  safe  to  forecast  the  issue  from 
the  haemorrhagic  symptoms  only.  This  is  still  more  true  if 
the  haemorrhage  is  less  pronounced,  or  of  the  less  serious 
kinds  ;  in  such  cases,  and  they  are  many,  all  hangs  upon  the 
nature  of  the  coincident  symptoms. 

CASES   WITH   SYMPTOMS  OF  HEMORRHAGE 

The  following  cases  have  been  selected  to  illustrate  the 
variety  of  haemorrhagic  symptoms  which  may  be  displayed, 
the  variety  in  the  course  of  the  illness,  and  the  variety  of 
result.  The  collection  does  not  reflect  the  frequency  with 
which  cases  of  different  degrees  of  severity  occur  in  practice, 
but  indicates  a  scale  of  severity,  any  note  of  which  may  be 
struck  by  a  particular  case. 


80  THE    DIAGNOSIS    OF    SMALLPOX 

Case  I. — Coii/luent  smallpox  with  subi'esicidar  hcemorrhage — 
Hecoven/. — A.  H.,  a  man  aged  38,  was  stated  to  have  been  vaccinated  in 
infancy  but  had  no  cicatrices.  During  the  first  two  days  of  illness  the 
symptoms  were  of  so  moderate  a  character  that  the  patient  kept  his  bed 
against  his  inclination.  The  outcrop  of  the  papular  rash  occurred  on 
the  third  day.  Thereafter,  the.re  was  a  great  deal  of  prostration  and 
considerable  toxsemic  pyrexia ;  by  the  sixth  day  of  illness  the  patient 
•was  very  ill  and  highly  delirious.  The  rash  was  confluent  on  the  face, 
but  not  of  excessive  numerical  severity.  The  lesions  were  soft,  and  slow 
in  evolution  ;  the  areolae  were  of  a  dull  red  colour  and  sluggish  in 
reaction,  and  on  the  legs  were  for  the  most  part  altogether  immobile. 
When  the  rash  had  become  vesicular,  it  was  very  noticeable  that 
haemorrhage  had  occurred  in  the  bases  of  a  large  number  of  the  vesicles. 
The  purplish  staining  of  the  lesions,  so  caused,  was  apparent  on  the  face, 
but  was  more  conspicuous  on  other  parts  of  the  body.  It  occurred  on 
the  trunk,  arms,  wrists,  and  legs,  but  was  worst  on  the  feet.  In  some 
parts  only  at  intervals  was  a  vesicle  stained,  but  in  other  places  a  large 
proportion  of  them.  The  general  effect  was  that,  especially  on  the  limbs, 
the  rash  was  extensively  discoloured.  There  were  no  other  haemorrhagic 
symptoms,  and  on  the  eighth  day  of  illness  the  other  symptoms  abated. 
The  succeeding  fever  of  suppuration  was  not  very  severe,  and  the 
patient  made  a  good  recovery. 

Case  II.— Toxic  smallpox — Subvesicular  hoBmorrhage — Death  from 
oedema  of  the  lungs.— C.  W.,  a  man  aged  32,  was  vaccinated  in  infancy 
and  had  two  cicatrices.  He  died  on  the  eleventh  day  of  illness.  The 
toxaemic  symptoms  were  pronounced,  but  not  of  the  first  severitj'. 
Towards  the  close  of  the  illness  the  patient  became  delirious.  The  out- 
crop occurred  on  the  fourth  day.  The  rash  was  extremely  profuse,  and 
on  the  face  was  superconfluent.  In  its  earliest  stage  it  was  of  a  vivid 
red  colour,  which  could  be  discharged  only  imperfectly  by  pressure  and 
on  the  legs  was  quite  immobile.  The  papules  were  soft ;  and  when  the 
lesions  became  vesicular,  they  were  still  limp  and  were  slow  in 
evolution.  On  the  legs  subvesicular  haemorrhage  developed  extensively ; 
the  backs  of  the  feet  and  the  shins  were  covered  with  plum-coloured 
vesicles.  The  ulnar  sides  of  the  forearms  became  similarly  affected, 
though  the  colour  in  those  situations  was  not  quite  so  deep  as  on  the 
legs.  There  were  no  other  hiemorrhagic  symptoms.  On  the  ninth  day 
of  illness  the  rash  on  the  face  had  become  pustular,  the  pustules  being 
small  and  distinctly  modified.  But  on  other  parts  of  the  body  the 
vesicles  showed  no  sign  of  modification,  and  presented  the  same  flat, 
limp  character  as  before.  In  some  places  the  cuticle  had  peeled  off,  and 
large  raw  surfaces  were  so  exposed.  Towards  the  close  of  the  illness 
the  patient  developed  oidema  of  the  bases  of  both  lungs,  and  rapidly 
became  cyanosed  and  died. 

Case  III — Toxic  smallpox — Death  on  the  tenth  day  of  illness 
from  pneumonia. — P.  G.,  a  boy  aged  8,  unvaccinated,  fell  ill  with 
symptoms  of  gradually  increasing  severity,  and   became   delirious  on 


H.EMORRHAGIC    SYMPTOMS  81 

the  tliird  day  of  illness.  The  patient  was  quiet  in  his  delirium,  but 
it  persisted  until  his  death.  The  focal  rash  appeared  on  the  third 
day,  and  was  very  abundant.  The  colour  was  vivid  and  not  very 
labile.  When  the  rash  attained  the  vesicular  stage,  many  of  the  lesions 
presented  a  purplish  subvesicular  staining;  this  appearance  was  most 
noteworthy  on  the  thighs.  The  first  decisive  sign  of  the  gravity  of 
the  illness  was  a  fetid  odour  of  the  breath,  first  noticed  on  the  fifth 
day  of  illness.  But,  earlier,  some  small  pink  petechiai  had  been 
noticed  scattered  about  the  body,  and  also  a  few  larger  cutaneous 
luL'morrhages  about  a  tenth  of  an  inch  across  ;  most  of  the  latter  were 
violet  in  colour,  but  two  of  them  were  purple-black.  On  the  sixth 
day  of  illness  the  boy  began  to  spit  up  blood-stained  mucus,  and  there 
"Were  some  signs  of  oedema  of  the  lungs.  A  bruise  half  an  inch 
across  appeared  on  the  forehead.  During  the  succeeding  days  the 
patient  seemed  better.  The  odour  of  the  breath  became  inoffensive, 
the  expectoration  ceased  to  be  blood-stained,  and  there  was  normal 
evolution  of  the  eruption.  But  in  the  end  the  child  developed 
pneumonia  and  died. 

Case  IV. — Toxic  smallpox — (Edema  of  the  lungs — Becovert/. — 
It  has  been  pointed  out  that,  though  the  symptoms  of  ha;morrhage 
are  an  expression,  they  are  not  necessarily  a  measure  of  the  severity 
of  the  toxtemia.  In  this  case  these  symptoms  were  conspicuous  ;  but 
though  the  other  toxamiic  symptoms  were  by  no  means  insignificant, 
the  case  was  exceptional,  not  so  much  because  the  patient  under  those 
circumstances  survived,  as  because  she  survived  also  the  pulmonary 
complication  which  is  so  generally  fatal.  On  the  third  day  of 
her  illness  the  patient,  L.  B.,  aged  27,  unvaccinated,  developed 
a  papular  rash  which  afterwards  became  confluent.  On  the  legs  many 
of  the  areoUy  became  blood-stained  ;  and  here  and  there  about  the 
body  and  limbs,  hajmorrhage  occurred  in  the  bases  of  some  of  the 
vesicles.  On  the  sixth  day  of  illness  there  was  an  attack  of  epistaxis. 
Some  extravasations  appeared  on  the  hard  palate,  and  the  fauces 
became  black  and  foul  from  effusion  of  blood  into  the  mucous  mem- 
brane. On  the  seventh  day  a  large  conjunctival  haemorrhage  de- 
veloped in  the  left  eye,  and  the  patient  began  to  cough  up  blood- 
stained mucus.  She  continued  to  expectorate  large  quantities  of 
blood-stained  fluid,  but  on  the  tenth  day  of  illness  the  secretion 
ceased  to  be  blood- stained.  Thereafter,  the  oedema  of  the  lungs  cleared 
up,  the  patient  developed  a  normal  secondary  fever  without  further 
complications,  and  made  a  good  recovery. 

Case  V. — I'oxic  smallpox — Death  on  the  tenth  day  from  oedema 
of  the  lungs. — A.  A.,  a  woman  aged  38,  had  been  vaccinated  in  infancy 
but  had  only  one  very  small  cicatrix.  The  onset  of  the  illness  was  very 
sudden,  the  pain  violent  and  lasting,  and  the  prostration  extreme. 
Except  for  a  few  hours  during  the  night  of  the  sixth  day,  the  mind 
remained  clear  throughout  the  illness.  The  outcrop  occurred  on  the 
third  day,  and  the  rash  was  abundant.  The  colour  of  the  papules  and 
G 


82  THE    DIAGNOSIS    OF    SMALLPOX 

areola?  was  dark  red,  and  was  imperfectly  mobile.  The  subsequent 
evolution  of  the  eruption  was  slow  and  imperfect,  the  vesicles,  when 
formed,  being  flat  and  limp,  and  showing  no  sign  of  suppuration  until 
shortly  before  death.  On  the  fourth  day  of  illness  a  petechial  rash 
appeared  in  the  groins  and  armpits  ;  additionally,  many  petechite  and  a 
few  larger  extravasations  were  scattered  irregularly  about  the  trunk 
and  upper  arms.  Epistaxis  set  in  on  the  sixth  day :  the  patient  was 
subject  to  this  symptom,  but  the  bleeding  was  unusually  severe  and 
continuous.  About  the  same  time,  uterine  hitmorrhage  developed  ;  and 
it  was  noticed  also  that  the  focal  rash  displayed  some  subvesicular 
hjemorrhage.  On  the  eighth  day  there  was  some  hctmoptysis.  On  the 
following  day  the  patient  rallied,  and  the  epistaxis  ceased.  But  she 
had  developed  oedema  of  the  lungs,  and  on  the  tenth  day  of  illness  was 
expectorating  large  quantities  of  watery  fluid.  The  respiration  increased 
in  rapidity,  and  the  patient  became  cyanosed  and  died. 

Case  VI. — Toxic  smallpox — Profuse  ]xipular  eruption — Death  on 
the  seventh  day  of  illness. — J.  A.,  a  married  woman,  aged  23,  un- 
vaccinated,  fell  ill  with  symptoms  of  gradually  increasing  severity.  On 
the  day  of  onset  she  got  up  in  the  morning,  but  returned  to  bed  later. 
On  the  day  following  she  was  worse,  the  prominent  symptoms  being 
vomiting,  headache,  pains  in  the  loins  and  general  prostration  ;  but  the 
symptoms  were  not  of  unusual  severity.  The  outcrop  occurred  on  the 
third  day  of  illness.  On  the  day  following  the  outcrop  abortion 
occurred,  the  pregnancy  being  of  two  months'  date.  During  this  time 
the  prostration  had  become  extreme ;  and  on  the  sixth  day  of  illness 
the  patient  was  collapsed,  looked  bloodless,  and  presented  a  facies 
typical  of  severe  forms  of  toxic  smallpox.  The  mental  faculties  were 
perfectly  clear.  The  odour  of  the  breath  was  horribly  fetid.  Except 
some  uterine  hjemorrhage  following  the  abortion,  the  first  haunorrhagic 
symptom  which  had  been  noticed  was  a  bruise,  which  formed  on  the 
left  hand  after  a  slight  blow  sustained  on  the  fifth  day  of  illness. 
During  the  night  of  that  day,  also,  there  had  been  severe  uterine 
haemorrhage.  On  the  sixth  day  there  was  extensive  extravasation  of 
blood  into  the  fauces,  the  throat  and  palate  becoming  black.  The  lips 
and  teeth  were  covered  with  bloody  crusts,  and  there  was  conjunctival 
haemorrhage  in  both  eyes.  There  was  a  slight  abrasion  on  the  forehead, 
from  which  blood  oozed.  Across  the  loins  was  a  band,  a  few  inches 
wide,  composed  of  numerous  petechite  lying  in  a  dusky  erythematous 
matrix  ;  but  that  affection  of  the  skin  was  confined  to  that  situation,  and 
did  not  invade  the  more  usual  situations  of  the  toxiemic  petechial  rash. 
Some  petechiae  were  scattered  irregularly  over  the  chest,  abdomen  and 
legs,  and  mingled  with  them  were  a  few  somewhat  larger  extravasations, 
ranging  in  colour  from  violet  to  purple-black.  On  the  arms  there 
were  several  small,  indistinct,  vein-like,  subdermal  extravasations,  in 
size  from  half-an-inch  to  one  inch  across.  In  addition,  there  was  a 
large  bruise  on  the  back  of  the  left  hand  and  another  on  the  right  hip. 
The  papular  rash  was  very  profuse.    On  the  face  the  papules  were  pale 


HEMORRHAGIC    SYMPTOMS  83 

and  very  hard  to  distinguish.  Elsewhere  they  were  more  conspicuous, 
but  everywhere  soft  and  ill-defined.  A  few  were  blood-capped. 
Throughout  the  illness  no  sign  of  vesiculation  was  observed  in  the 
lesions.  On  the  evening  of  the  sixth  day  there  was  again  profuse 
hjemorrhage  from  the  uterus,  which  continued  until  death.  Early  in 
the  morning  of  the  seventh  day  of  illness  the  patient  complained  of 
pain  over  the  heart,  became  cyanosed  and  pulseless,  and  died.  She  was 
conscious  until  within  a  few  minutes  of  death. 

Ca^  VII. — Toxic  smallpox — Scant;/  papular  rash — Death  on  the 
seventh  day  of  illness.— "hi.  J.  H.,  a  girl  aged  12,  was  vaccinated  in 
infancy  but  presented  only  one  very  small  cicatrix.  The  focal  rash  was 
first  observed  on  the  fifth  day  of  illness,  but  the  rash  was  composed 
onlj'  of  a  few  papules,  and  there  were  none  except  on  the  forehead. 
Even  at  the  time  of  death  the  lesions  had  not  materially  increased  in 
number,  and  had  not  become  vesicular  ;  but  by  that  time  a  few  papules 
could  be  detected  on  other  parts  of  the  body  besides  the  face.  The  ill- 
ness did  not  begin  very  suddenly.  On  the  day  of  onset  the  child  got 
up  in  the  morning  but,  feeling  unwell,  had  to  go  back  to  bed.  She 
complained  of  headache,  and  of  pain  in  the  back  and  legs  ;  and  there 
was  some  vomiting.  On  the  second  day  of  illness  there  were  some 
attacks  of  shivering  ;  and  during  that  and  the  succeeding  days  the  child 
became  progressively  worse,  and  was  delirious  at  night.  On  the  third 
day  of  illness  there  were  a  few  attacks  of  epistaxis,  and  some  blood  was 
vomited.  On  the  fourth,  some  petechiie  were  noticed  about  the  body. 
A  large  number  of  these  soon  made  their  appearance  ;  yet  they  were 
not  so  distributed  as  to  suggest  a  toxajmic  petechial  rash,  but  were 
scattered  haphazard  about  the  trunk,  the  shoulders,  and  the  upper  parts 
of  the  thighs.  Here  and  there,  scattered  with  the  petechias,  were  a  few 
small  purple  extravasations,  in  size  near  that  of  a  pea.  Vomiting  of 
altered  blood  continued  to  occur  at  intervals,  and  on  the  sixth  day 
blood  became  effu.<ed  into  the  conjunctivie  of  both  eyes,  and  a  large 
effusion  occurred  deeply  in  the  left  calf.  The  pulse  became  very  rapid, 
and  death  took  place  early  on  the  seventh  day  of  illness.  The  delirium 
continued  to  the  end. 

Case  VIII. — Toxic  smallpox — Death  on  the  sixth  day  of  illness 
before  the  outcrop. — H.  B.,  a  man  aged  25,  unvaccinated,  suffered  the 
customary  symptoms  of  onset  and  the  succeeding  prostration.  On  the 
fourth  day  of  illness  a  petechial  toxaemic  rash  appeared.  This  covered 
the  chest  and  abdomen,  groins  and  axilhe,  and  extended  on  to  the 
shoulders  and  upper  parts  of  the  arms,  and  on  to  the  inner  and  front 
part  of  the  thighs.  The  rash  extended  also  across  the  loins.  The 
affected  parts  rapidly  gained  depth  of  tint  and  became  the  seats  of 
innumerable  petechiae ;  at  the  close  of  the  illness  that  portion  of  the 
skin  presented  one  continuous  sheet  of  violet  haemorrhagic  discolora- 
tion. A  few  irregular  patches  of  discoloration  developed  also  on  the 
forearms,  hands,  and  legs  ;  in  the  last  situation,  chiefiy  along  the  course 
of  the  internal  saphenous  vein.    Conjunctival  haemorrhage  developed  in 


84  THE    DIAGNOSIS    OF    SMALLPOX 

both  eyes.  On  the  fifth  day  of  illness  the  patient  began  to  spit  blood, 
and  the  fauces  became  intensely  discoloured  from  extravasation  into 
the  raucous  membrane.  On  the  sixth  day,  a  few  hours  before  death, 
there  was  hsematuria.  No  focal  rash  appeared,  with  tlie  exception  that 
one  small  vesicle  was  noticed  on  the  back  of  the  right  hand. 

Case  IX. — Toxic  smalljiox  in  a  new-horn  infant — Death  on  the  second 
day  of  illness.— 'E.  B.,  a  female,  the  child  of  a  variolous  mother,  dis- 
played no  abnormal  symptom  during  the  first  four  days  of  life.  On  the 
fifth  day  she  took  food  badly  and  seemed  ailing..  On  the  following  day 
the  child  was  weak,  and  had  cold  extremities  and  pale  lips.  At  5  a.m. 
some  red  frothy  blood  was  vomited.  At  11.30  a.m.  blood  was  vomited 
for  the  second  time  and  in  considerable  quantity.  At  1.30  p.m.  the 
child  vomited  blood  for  the  third  time.  She  died  suddenly  half-an-hour 
later.  No  other  hemorrhagic  symptom  was  observed  during  life,  and 
there  was  no  focal  rash.  At  the  autopsy,  signs  were  observed  which 
were  characteristic  of  death  from  toxic  smallpox.  The  child  was 
vaccinated  on  the  day  of  birth,  and  at  the  time  of  death  displayed  the 
first  signs  of  a  successful  vaccinal  reaction. 


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PLATE   LXXXIV. 

Fig.  1. — This  is  a  reproduction  on  a  large  scale  of  a  pcirt.  of  the  photograph 
rendered  in  the  last  print.  The  intrapustular  and  the  extramural 
extravasations  are  more  clearly  distinguished  (b  and  a).  In  many 
instances  the  distinction  was  displayed  by  the  same  lesion,  a  lighter 
ring  separating  the  black  centre  from  the  peripheral  zone. 

Fig.  2. — The  thighs  of  a  patient  dead  of  hseraorrhagic  smallpox.  Death 
occurred  before  the  outcrop  of  the  focal  rash.  The  black  spots  seen  in 
tl>e  print  represent  circumscribed  bloody  extravasations  into  the  skin, 
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line  encircling  the  thigh.  This  was  a  linear  extravasation,  ,and  was 
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CHAPTER  XII 

HiEMORRHAGIC    OR    TOXIC    SMALLPOX 

So  protean  is  the  disease,  and  especially  this  graver  phase  ot 
it,  that  but  for  the  teaching  of  experience  some  of  its  manifold 
types  might  be  taken  for  distinct  disorders.  But  the  types 
merge  into  one  another.  Toxic  smallpox  is  of  one  kind 
though  of  many  degrees ;  and  perhaps  there  is  more  to  be 
lost  in  clearness  than  can  be  gained  in  convenience  by 
attempting  a  classification  which  shall  lock  off  sections 
in  the  stream  of  cases.  The  features  common  to  all  cases, 
or  peculiar  to  some,  will  therefore  be  grouped  together  and 
discussed  under  appropriate  headings.* 

Constitutional  symptoms. — The  description  of  the  tox- 
ajmic  symptoms,  given  in  Chapter  IX.,  would  lack  vigour 
if  applied  to  these  graver  cases.     The  onset  may   be  more 

•  Slany  authors  follow  Ciirschmann  (Ziemssen's  Cyclopaedia)  in  his  classifi- 
cation or  terminology.  In  descriptions  of  smallpox  it  is  a  common  practice  to 
distinguish,  under  the  names  of  "  initial  illness "  or  "  prodromal  stage,"  that 
part  of  the  toxaemic  fever  which  occupies  the  interval  between  the  onset  of 
illness  and  the  outcrop  of  the  focal  rash.  That  such  a  distinction  is  arbitrarj'  is 
of  little  moment  in  the  description  of  ordinary  cases.  But  Curschmann  pursues 
it  in  the  discussion  of  toxic  smallpox,  when-  it  becomes  the  source  of  some 
confusion.  He  divides  toxic  cases  into  two  prroups,  the  first  of  which  he  calls 
"  purpura  variolosa,"  and  defines  as  '•  the  initial  stage  of  variola  which  has 
become  hfemorrhagic,"  and  the  second  "  variola  hajmorrhagica  pustulosa," 
under  which  head  he  includes  cases  in  which  the  focal  lesions  become  foci  of 
hasmorrhage.  Unfortunately  these  divisions  are  neither  all-embracing  nor 
mutually  exclusive.  And  the  terms  themselves  are  liable  to  be  misunderstood. 
For  on  account  of  the  modem  limitation  in  meaning  of  the  English  word 
"  pustule,"  the  term  "  variola  ha?morrhagica  pustulosa  "  is  apt  to  be  taken  to 
refer  to  cases  in  which  hajmorrhage  occurs  during  the  pustular  stage  of  the 
disease ;  cases  which,  though  falling  strictly  within  Curschmann's  definition, 
are  not  eases  of  toxic  smallpox  {see  p.  75).  Neither  is  the  term  "purpura 
variolosa  "  free  from  objection,  because  it  is  liable  to  be  applied  to  cases  in 
which  a  purpuric  toxaemic  rash  is  developed  ;  and  such  cases,  again,  are  not  in 
general  toxic  cases. 

83 


86  THE    DIAGNOSIS    OF    SMALLPOX 

sudden,  the  pains  more  acute ;  and  the  collapse  is  more 
profound.  Yet  it  would  be  a  great  mistake  to  suppose  that  a 
fatal  toxaemia  is  always,  or  even  generally,  ushered  in  very 
suddenly  and  by  symptoms  of  unwonted  severity.  Perhaps 
in  most  cases  one  is  not  led  at  first  to  suspect  the  gravity  ot 
the  illness  which  is  about  to  develop  ;  and  it  is  not  until  the 
second  or  third  or  even  fourth  day  of  illness  that  the  full 
severity  of  the  symptoms  becomes  unmasked.  On  the  other 
hand,  it  must  be  remembered  that  alarming  symptoms  are  not 
necessarily  the  prelude  to  a  fatal,  or  even  to  a  serious,  illness. 
It  will  be  understood  that  the  description  of  an  illness 
of  the  more  serious  kind  will  fit  some  cases  in  which  the 
issue  is  never  in  serious  doubt ;  and  at  the  same  time  will 
mark  a  standard  to  which  some  cases  of  toxic  smallpox 
never  attain. 

Pain. — The  pains,  in  some  of  these  cases,  are  of  extra- 
ordinary severity.  The  head  may  feel  as  though  the  skull 
were  opening  and  shutting ;  the  lumbar  pain  may  be  com- 
pared to  a  sensation  as  of  the  grinding  together  of  the  bones 
of  the  pelvis.  These  pains  are  an  early  developed  and  a 
persistent  symptom,  so  that  a  patient  may  not  be  free  ot 
them  until  the  natural  end  of  the  toxsemic  fever,  if  death  be 
delayed  so  long. 

Prostration. — An  impressive  feature  of  these  cases,  though 
one  shared  by  all  cases  marked  by  a  severe  toxemia,  is  the 
excessive  prostration  of  the  patient.  The  prostratioti  develops 
-svith  a  rapidity  corresponding  to  the  more  or  less  sudden 
onset  of  the  illness,  but  is  not  at  its  height  until  the  lapse 
of  the  first  two  or  three  days.  It  is  then  marked  by  a  loss  of 
tone  of  the  whole  muscular  system. 

On  the  face  this  symptom  impresses  a  very  characteristic 
appearance  which,  once  observed,  is  not  difficult  to  recognise. 
(Plates  Lxxxvi.  and  lxxxvii.)  The  relaxation  of  the  muscles 
of  expression  makes  the  patient  look  dull  and  apathetic. 
The  features  are  immobile,  the  lines  of  expression  obliterated, 
the  cheeks  relaxed.  The  lips  are  full  and  parted,  dry,  with 
sordes  on  them,  or  perhaps  encrusted  with  dry  clouts  of 
blood.     The  skin  may  be  flushed  or  pale.     The  eyelids  droop, 


HiEMORRHAGIC    OR    TOXIC    SMALLPOX       87 

and  it  seems  to  be  an  effort  to  lift  them  ;  yet,  when  the  lids  are 
raised,  the  eyes  look  bright  and  shining.  (Plate  Lxxxviir.  and 
Lxxxix.,  Fig.  1.)  The  ocular  muscles  share  in  the  symptoms, 
and  the  patient  is  apt  to  follow  a  moving  object  by  a  movement 
of  the  head  rather  than  of  the  eyes.  When  he  is  addressed, 
it  is  seen  that  his  fticulties  are  clear ;  but  he  rouses  himself 
with  an  effort,  answers  with  deliberation,  and  relapses  into 
apathy.  Except  that  he  breathes  easily,  he  looks  like  a  man 
who  has  just  undergone  a  great  and  sustained  physical  exer- 
tion ;  like  a  runner  after  the  race,  self-centred,  absorbed  in 
the  attempt  to  renew  his  exhausted  powers. 

With  a  prostration  so  profound,  it  is  not  surprising  that 
the  course  of  the  illness  may  be  interrupted  by  attacks  of 
collapse,  during  which  the  patient  displays  a  clammy  skin, 
cold  extremities,  a  feeble  pulse,  and  perhaps  some  cyanosis. 
Such  a  condition  is  liable  to  be  brought  about  by  some  effort, 
little  enough  in  itself,  perhaps,  but  disproportionate  to  his 
enfeebled  powers.  Even  the  less  serious  forms  of  toxsemic 
fever  are  not  infrequently  marked  by  symptoms  of  collapse 
when  the  patient  has  overtaxed  his  capacity  for  exertion. 
Sometimes  the  heart-failure  is  still  more  profound,  and  is 
signalised  by  cardiac  pain  and  a  fluttering  pulse.  From  such 
an  attack  of  syncope  the  patient  may  rally,  or  it  may  prove 
rapidly  fatal. 

In  exceptional  cases  the  aspect  which  has  been  described 
is  concealed  by  the  anxiety  and  distress  caused  by  the 
intensity  of  the  poisoning.  (Plate  lxxxviii.)  The  stimulus  of 
an  excessive  dose  may,  indeed,  be  such  as  to  mask  all  the  pros- 
tration on  which  that  aspect  depends ;  and  the  patient  may 
exhibit  a  deceptive  capacity  for  exertion,  until  he  collapses 
upon  the  brink  of  death. 

Mental  symptoms. — The  usual  mental  symptoms  are 
persistent  sleeplessness  and  an  unnatural  clearness  of  the 
intellect,  so  that  the  patient  shall  miss  nothing  of  his  suffer- 
ings. In  some  cases  the  mind  becomes  clouded,  or  there  is 
delirium  ;  but  generally  only  towards  the  close.  Yet,  with 
children,  nocturnal  delirium  is  common  earlier  in  the  illness. 

Pyrexia. — From    case   to  case  the  curve  of  temperature 


88 


THE    DIAGNOSIS    OF    SMALLPOX 


presents  considerable  variation.  In  some  cases,  and  those 
generally  the  worst,  a  low  temperature  prevails,  and  the 
thermometer  may  never  record  100^.  In  other  cases,  especi- 
ally those  in  which  life  is  most  prolonged,  a  high  temperature 
is  the  rule.  (Charts  ix.  and  x.)  This  inverse  proportion 
between  the  height  of  the  temperature  and  the  severity  of  the 


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Chart  ix. — Toxic  Smallpox. 
Temperature  Low, 


Chart  x. — Toxic  Smallpox. 
Tempeh.\ture  High. 


attack  is  common  both  to  toxic  smallpox  and  to  toxic  scarlet 
fever,  though  with  toxic  scarlet  fever  the  low  temperature  is 
very  much  less  common.  With  smaUpox,  besides,  discrepancies 
are  common  in  similar  cases,  so  that  the  thermometer  is  not 
of  much  use  in  forecasting  the  probable  course  of  the  ill- 
ness.    Even   when   the  fever  runs   high,   the  end  may  be 


H.EMORRHAGIC    OR    TOXIC    SMALLPOX       89 

preceded  b}^  a  fell  of  temperature.     On  the  other  hand  there 
may  be  terminal  hyperpyrexia.     (Charts  xi.  and  xii.) 

When  the  illness  is  protracted,  it  may  happen  that  the 


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Chart  xi. — Toxic  Smallpox. 
Low   Terminal   Temperature. 


Chart  xii. — Toxic  Smallpox. 
High   Terminal  Temperature. 


patient  will  survive  the  onset  of  the  eruptive  fever.  In  such 
a  case,  as  in  most  cases  of  confluent  smallpox,  the  distinction 
between  the  two  febrile  states  may  be  indicated  on  the  chart 
by  a  dip  in  the  curve  of  temperature.     (Chart  xiii.)     But 


90 


THE    DIAGNOSIS    OF    SMALLPOX 


frequently  this  break  in  the  curve  is  obHterated,  either  by 
the  febrile  effect  of  some  complication,  or  else  by  the  blending 
of  the  two  fevers. 


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Chart  xiii. — Toxic  Smallpox.     Tox-*:mic  Pyrexia  Distinct 

FROM    SuPPtRATnE. 


Foetor. — There  are  a  few  other  symptoms  of  which  it  is 
necessary  to  take  account.  The  most  easily  observed  is  a 
fetid  odour  of  the  breath.  This  sign  is  very  commonly, 
though  not  invariably,  met  with  in  toxic  cases ;  on  the  other 
hand  it  is  occasionally  to  be  observed  in  cases  which  hardly 
attain  to  the  toxic  standard.  The  symptom  will  not  be  con- 
fused with  the  foul  odour  encountered  in  certain  cases  of 
confluent  smallpox,  which  is  merely  an  emanation  from  the 
suppurating   skin.     And  the  foetor,  probably,  does  not  arise 


HEMORRHAGIC    OR    TOXIC    SMALLPOX       91 

from  the  foul  condition  of  the  throat  which  occurs  in  some 
cases  of  toxic  smallpox  o^ving  to  extravasation  of  blood  into 
the  mucous  membrane;  for  the  foetor  may  be  observed  in 
cases  in  which  the  throat  is  unaffected.  The  odour  seems  to 
be  an  exhalation  from  the  lungs,  arising  from  certain  changes 
in  the  blood.  It  is  a  sickly  odour,  unique  in  the  catalogue  ot 
nasty  smells,  and  a  breath  of  it,  once  inhaled,  will  dwell  for 
ever  in  the  recollection.  The  sign  is  often  the  first  danger 
signal  displayed  in  the  course  of  the  illness. 

Alhuminuria. — Albuminuria  may  occur  as  an  early  and 
transient  symptom  of  more  than  one  of  the  specific  fevers, 
and  it  is  met  with  very  frequently  in  cases  of  confluent 
smallpox.  In  toxic  cases  it  is  especially  common  and  con- 
spicuous, even  when  unassociated  with  htematuria. 

Enlargement  of  the  liver. — A  less  constant  symptom  than 
the  last  is  a  rapid  and  painless  enlargement  of  the  liver. 
Like  albuminuria,  this  symptom  is  liable  to  attend,  not  only 
the  toxic,  but  also  all  the  severer  forms  of  smallpox.  The 
enlargement  becomes  perceptible  towards  the  end  of  the 
toxsemic  fever,  and  continues  its  progress  during  the  first 
part  of  the  fever  of  suppuration.  But  in  toxic  cases  the 
symptom  may  be  apparent  earlier  in  the  illness  and  become 
very  pronounced.  Therefore,  when  other  signs  are  indistinc- 
tive, some  importance  attaches  to  the  perception  of  the  liver's 
edge,  one  or  two  fingers'  breadth  below  the  cartilages,  moving 
downwards  from  day  to  day.  Sometimes  the  spleen  is 
enlarged  and  perceptible  to  the  touch,  but  far  less  frequently 
than  the  liver. 

Termination. — Patients  who  die  of  hsemorrhagic  small- 
pox do  not  die  of  haemorrhage.  The  prostration  which  they 
suffer  is  evidence  of  a  disturbance  of  the  heart  which  is 
often  so  profound  as  to  be  fatal.  Those  who  are  killed  by 
the  toxfemia  die,  almost  invariably,  either  from  heart-failure, 
or  from  a  common  and  fateful  complication,  oedema  of  the 
lungs. 

Oedema  of  the  lungs  takes  time  to  develop  and  to  kill; 
Heart-fixilure,  therefore,  is  the  cause  of  death  when  the 
disease   kills  quickly.     The  end   may  be  sudden  from    syn- 


92  THE    DIAGNOSIS    OF    SMALLPOX 

cope ;  or  its  approach  may  be  more  gradual,  and  marked 
by  a  failing  pulse,  increasing  pallor,  and  cyanosis.  (Cases 
VI.  and  VII.,  Chapter  XL) 

In  the  more  protracted  cases  heart-failure  may  be  still 
the  cause  of  death.  But  more  often  the  lungs  become  en- 
gorged and  sodden,  and  the  patient  is  likely  to  expectorate 
quantities  of  clear  or  blood-stained  fluid  and  to  die  water- 
logged, drowned  in  his  own  secretion.  Even  though  the 
patient  survive  this  condition,  it  may  be  only  to  die  of 
pneumonia.     (Cases  ii.,  in.  and  v..  Chapter  XI.) 

Recovery. — The  frequency  of  recovery  from  toxic  small- 
pox will  depend  upon  the  definition  of  the  term.  If  the 
condition  is  defined  by  reference,  not  only  to  the  hsemor- 
rhagic,  but  also  to  the  other  symptoms,  cases  of  recovery 
are  very  exceptional.  A  patient,  for  instance,  may  develop 
hsematuria  together  with  certain  other  less  important  symp- 
toms of  haemorrhage  ;  yet  he  may  suffer  so  little  prostration 
that  the  issue  will  be  hardly  in  serious  doubt.  Such  cases 
are  met  with  occasionally,  and  it  would  be  a  misuse  of  terms 
to  instance  them  as  cases  of  recovery  from  toxic  or  hsemor- 
rhagic  smallpox. 

Though  recovery  is  so  exceptional  when  the  patient  ex- 
hibits, not  only  pronounced  hsemorrhagic  symptoms,  but  also 
excessive  prostration,  the  characteristic  facies,  or  the  factor 
oris,  yet  as  a  matter  of  fact  such  patients  often  survive  the 
toxaemia.  And  the  termination  of  that  stage  of  the  illness 
is  sometimes  very  well  defined.  The  pains  disappear,  if  they 
have  lasted  so  long,  the  symptoms  of  collapse  pass  off,  and 
the  patient  loses  the  facies  and  the  sense  of  prostration 
which  the  collapse  provoked.  But  these  omens  are  generally 
illusory.  Death,  probably,  will  soon  be  brought  about  by 
cedema  of  the  lungs,  which  the  toxaemia  has  already  en- 
gendered, or  by  pneumonia  arising  out  of  it.  If  the  patient 
escape  those  dangers,  the  focal  rash  will  be  likely  to  prove 
fatal.  In  most  of  these  cases  the  rash  is  profuse  and  is 
sufficient  to  kill,  in  the  earliest  stage  of  its  suppuration,  a 
patient  already  worn  out  by  the  previous  illness.  Some- 
times, however,   the   patient   does  not   succumb   until  late 


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HiEMORRHAGIC    OR    TOXIC    SMALLPOX       93 

in    the    secondary    fever,    and    occasionally    recovers    com- 
pletely. 

Complete  recovery  from  toxic  smallpox  is  generally 
attributable  to  the  fact  that  the  rash  is  of  moderate  severity 
only,  or  is  partly  modified.  It  has  been  pointed  out 
(Chapter  IX.,  p.  63)  that  a  severe  toxaemia  is  not  necessarily  the 
prelude  to  an  abundant  focal  rash ;  and  that  a  total  loss 
of  immunity  to  the  toxaemia  may  co-exist  with  the  reten- 
tion of  some  immunity  to  the  eruptive  fever.  It  follows  that, 
though  with  toxic  smallpox  it  is  the  rule  for  the  rash  to 
be  excessive  if  the  patient  lives  long  enough  for  it  to  develop, 
yet  in  some  cases  the  rash  will  not  be  very  abundant, 
and  in  others  will  display  some  degree  of  modification. 
(Plate  Lxxxv.,  Fig.  1.)  It  is  usually  in  such  circumstances 
that  recovery  from  toxic  smallpox  occurs. 

Duration  and  course. — In  exceptional  cases,  which 
there  is  no  hesitation  to  class  as  toxic,  life  is  prolonged  far 
into  the  secondary  fever.  But  as  a  rule  the  patient  does  not 
survive  beyond  the  eighth  day  of  efflorescence ;  a  date  which 
would  correspond,  in  most  cases,  with  the  tenth  or  eleventh 
day  of  illness. 

With  natural  smallpox  the  onset  of  suppuration  occurs  on 
the  fifth  day  of  efflorescence,  and  by  the  eighth  the  eiiiption 
has  completely  matured.  With  toxic  smallpox,  also,  the 
course  of  events  in  that  respect  may  be  not  materially  different ; 
that  is  to  say,  a  patient,  dying  on  the  eighth  day  of  efflor- 
escence, may  display  a  pustular  eruption.  (Cases  ii.  and 
III.,  Chapter  XL,  and  Chart  xiii.,  p.  90.)  But  in  many  other 
instances  life  may  be  prolonged  to  the  same  extent,  and  yet 
suppuration  may  hardly  become  evident. 

Such  delay  in  the  advent  of  suppuration  is  occasioned  by 
the  undue  severity  and  duration  of  the  toxasmic  fever.  In 
most  cases  of  toxic  smallpox  the  outcrop  occurs  at  the  usual 
time,  that  is  to  say,  on  the  third  or  fourth  day  of  illness. 
Yet,  as  was  pointed  out  in  Chapter  VI.  (p.  42),  an  excessively 
severe  toxaemia  is  capable  of  retarding  all  stages  of  the 
subsequent  evolution  of  the  eruption.  (Cases  v.  and  vi., 
Chapter  XL,  and  Chart  xi.,  p.  89.) 


94  THE    DIAGNOSIS    OF    SMALLPOX 

The  toxsemic  fever  may  be  prolonged,  also,  by  a  protracted 
interval  between  the  onset  of  the  illness  and  the  outcrop  of 
the  rash  (see  Chapter  IX.,  p.  62).  The  outcrop  may  be  post- 
poned until  after  the  fourth,  or  fifth,  or  even  the  sixth  day  of 
illness.  A  delayed  outcrop  is  a  feature  of  some  of  the  worst 
cases.     (Case  vii..  Chapter  XL) 

On  account  of  this  variety  in  the  possible  course  of  the  ill- 
ness, there  is  no  uniformity  of  clinical  aspect  about  patients 
who  have  been  ill  for  the  same  length  of  time.  Patients 
even,  whose  eruptions  are  of  the  same  age  may  display  con- 
siderable variety  in  the  character  of  the  rash. 

The  worst  forms  of  an  illness  are  generally  the  least 
common,  and  cases  of  toxic  smallpox  occur  with  a  frequency 
which  is  in  inverse  proportion  to  the  rapidity  of  the  fatal 
issue.  Most  cases  are  fatal  after  the  seventh  day  of  illness ; 
and  in  such,  whatever  its  precise  character  may  be,  a 
pronounced  eruption  is  almost  always  developed  before  the 
end  of  the  illness. 

When  the  date  of  death  falls  between  the  fifth  and  seventh 
day  of  illness,  there  is  much  more  inconstancy  as  to  the 
prominence  which  the  eruption  attains.  A  well-developed 
vesicular  rash  may  be  seen  in  a  case  fatal  on  the  fifth  day, 
and  but  a  few  scanty  papules  in  a  case  fatal  on  the  seventh. 

Patients  sometimes  die  before  the  outcrop.  In  such  cases, 
for  the  reasons  already  set  forth,  it  by  no  means  follows  that 
the  illness  is  of  the  briefest.  (Case  viii.,  Chapter  XI.)  In  the 
majority  of  instances  the  patient  does  not  die  before  the 
fourth  day.  Indeed,  death  earlier  than  the  fourth  day  is 
altogether  exceptional ;  yet  it  is  possible  for  the  toxaemia  to 
kUl  in  little  more  than  twenty-four  hours. 


CHAPTER   XIII 

HEMORRHAGIC    OR    TOXIC    SMALLPOX    (concluded) 

The  focal  rash. — The  clinical  character  of  a  case  depends 
chiefly  upon  the  prominence  attained  by  the  focal  rash.  If 
the  eruption  is  absent  or  inconspicuous,  the  case  is  dominated 
by  the  constitutional  and  haemorrhagic  symptoms;  but  in 
most  cases,  however  the  illness  commenced,  the  skin  affection 
ultimately  usurps  the  attention,  and  the  disease  seems  to  be 
almost  as  much  a  dermatosis  as  a  constitutional  disorder. 

The  kind  of  rash  met  with  in  the  commonest  sort  of  case 
has  already  been  described  in  Chapter  VL  (p.  40).  The  rash 
is  profuse ;  on  the  face  it  is  confluent  or  superconfluent.  In 
its  earlier  stage  it  is  generally  bright  red ;  occasionally  the 
colour  tends  to  a  dusky  tint ;  it  is  pale  only  when  the  pros- 
tration is  extreme.  The  papules  are  soft,  and  often  incon- 
spicuous individually.  The  vesicles  are  flat,  flaccid,  and  slug- 
gish in  evolution.  (Plate  lxxxix.)  In  some  cases  the  cuticle 
becomes  detached,  here  and  there,  and  blebs  are  formed  con- 
taining blood-stained  serum. 

The  capacity  of  the  lesion  to  provoke  effusion  of  blood 
increases  with  its  progress  in  evolution.  Many  cases  in  which 
the  rash  becomes  vesicular  are,  therefore,  distinguished  by 
pronounced  hajmorrhagic  extravasations  about  the  lesions. 
(Plate  xc.)  Yet  it  must  be  remembered  that  the  promi- 
nence which  this  symptom  attains  is  governed  very  much  by 
individual  idiosyncrasy.  In  many  cases  of  confluent  small- 
pox, approximating  to  the  malignant  type  but  sustaining  no 
claim  to  be  called  toxic,  the  lesions  exhibit,  here  and  there, 
more  especially  on  the  Ihnbs,  purplish  subvesicular  staining  or 
violet-tinted  areolae.  And  there  are  cases  of  toxic  smallpox 
in  plenty,  with  well-developed  focal  rashes,  which  display 
hsemorrhagic  extravasations  of  no  greater  prominence. 

9a 


96  THE    DIAGNOSIS    OF    SMALLPOX 

When  death  occurs  before  the  rash  has  passed  beyond  the 
papular  stage,  even  though  the  papules  may  have  been 
developed  in  abundance,  haemorrhage  about  them  is  generally 
absent  or  inconspicuous.  Yet  of  some  such  cases  these  extra- 
vasations form  a  prominent  feature.     (Plate  xci.) 

When  the  patient  dies  before  the  efflorescence  is  completed 
the  rash  is  likely  to  be  still  more  anomalous  than  in  the  cases 
already  considered.  The  papules  are  soft,  pale,  and  almost 
flush  with  the  surface  of  the  skin.  If  hardly  perceptible  to 
the  eye,  they  are  still  less  obvious  to  the  touch.  And  what 
makes  the  case  still  more  puzzling  is  that  the  suppression  of 
the  development  of  papules  is  apt  to  be  more  complete  on  the 
face  than  elsewhere,  because  the  face,  being  naturally  best 
supplied  with  blood,  suffers  most  from  the  depression  of  the 
circulation.  Under  these  circumstances,  Avhen  the  observer 
is  confronted  with  an  eruption,  anomalous  both  in  the 
character  of  its  lesions  and  in  their  apparent  distribution, 
it  is  not  surprising  that  the  nature  of  the  case  is  easy  to 
mistake.  Cases  in  which  death  wholly  anticipates  the 
efflorescence  are,  in  reality,  very  exceptional.  More  often, 
when  cases  of  that  repute  occur,  it  is  possible  to  detect 
a  few  papules  if  they  are  sought,  not  on  the  face,  but 
on  some  part  of  the  body  where  the  circulation  is  less 
impaired. 

The  symptoms  of  haemorrhage. — Even  when  these  symp- 
toms are  pronounced,  no  patient  runs  up  the  whole  gamut 
of  expression  of  the  hsemorrhagic  tendency.  There  are, 
therefore,  many  possible  combinations  of  the  symptoms  and 
corresponding  variety  in  the  aspect  of  the  case.  Such  dif- 
ferences are  determined  by  no  sort  of  rule.  Whether  death 
comes  early  or  late,  whether  the  focal  rash  is  well  or  ill  de- 
veloped, the  food  or  air-passages,  the  lungs,  the  kidneys,  or 
the  cutaneous  surface  may  be  the  seat  of  the  dominating 
hsemorrhagic  symptom,  or  any  combination  may  fall  to  be 
endured. 

It  must  not  be  assumed  that  the  nature  of  the  attack  is 
always  advertised  boldly  in  symbols  of  blood.  Even  if  the 
haemorrhagic  symptoms  do  ultimately  become  conspicuous, 


HvEMORRHAGIC    OR    TOXIC    SMALLPOX       97 

in  most  cases  they  are  not  of  very  early  development.  In  the 
action  of  the  toxin  on  the  blood-vessels,  time  seems  to  be  an 
element  of  importance ;  and,  as  a  rule,  the  ha3morrhagic 
symptoms  do  not  appear  until  late  in  the  illness,  and  perhaps 
not  until  near  its  close. 

In  a  minority  of  cases  the  symptoms  of  haemorrhage  never 
become  very  prominent.  Most  of  such  cases  are  near  the 
borderland  of  the  class.  Yet  these  symptoms  are  not 
necessarily  pronounced  when  the  attack  is  of  the  first  severity. 
New-bom  babies  are  especially  susceptible  to  the  operation  of 
the  toxin,  and  occasionally  die  of  toxic  smallpox  with  the 
hsemorrhagic  symptoms  wholly  suppressed. 

A  child,  10  days  after  birth,  developed  a  very  scanty  variolous  rash, 
the  papules  being  very  soft  and  inconspicuous  even  at  the  time  of  death, 
which  occurred  four  days  later.  Death  was  sudden.  No  haemorrhage 
was  observed  during  life,  but  at  the  autopsy  a  few  trivial  internal 
extravasations  were  found. 

Such  cases  suggest  that,  in  excessive  doses  or  in  highly 
susceptible  subjects,  the  toxin  may  sometimes  paralyse  the 
heart  before  it  can  injure  the  vessels. 

Toxic  rashes. — Petechiaj  and  such  small  cutaneous  ex- 
travasations are  exceptional  in  often  making  their  appearance 
earlier  in  the  illness  than  most  other  hsemorrhagic  signs. 
That  circumstance  is  of  service  to  the  observer  when  the 
petechia  are  components  of  a  purpuric  rash. 

The  purpuric  rash. — The  purpuric  rash,  described  in 
Chapter  X.,  is  seen  in  a  considerable  proportion  of  toxic  cases. 
But  it  is  sometimes  so  vivid  and  extensive,  and  the  tendency 
to  blood-staining  is  so  nmch  exaggerated,  that  its  identity  is 
apt  to  be  obscured  and  its  real  nature  to  escape  recognition. 
In  such  cases  the  surface  affected  is  packed  densely  with 
small  petechife  and  pricked  out  with  larger  shot  -  like 
extravasations ;  while  the  erythematous  matrix  in  which 
these  are  embedded  may  appear  as  a  broad  sheet  of  dark-red 
or  violet  discoloration.  (Case  viii..  Chapter  XI.)  Sometimes 
the  change  goes  further,  and  the  surface  is  splashed  with 
irregular  patches  of  purple  in  which  the  finer  markings  are 

H 


98  THE    DIAGNOSIS    OF    SMALLPOX 

lost.  First  seen  thus,  the  best  part  of  the  skin  of  the  trunk  all 
claret-stained,  it  may  never  suggest  itself  that  the  rash  is 
generically  the  same  as  the  familiar  stippled  erythema  limited 
to  the  region  about  the  groins. 

There  is  another  reason  which,  in  toxic  cases,  is  apt  to 
make  this  rash  more  difficult  of  recognition.  It  has  been 
mentioned  that  in  some  cases  the  erythematous  basis  of  the 
purpuric  rash  encroaches  beyond  its  normal  limits.  (Chapter 
X.,  p.  68.)  This  is  most  likely  to  happen  when  the  patient 
has  toxic  smallpox;  the  back  and  limbs  may  be  then  ex- 
tensively invaded  by  the  erythema,  and  even  the  whole  body 
covered.  But  whereas,  ordinarily,  such  an  overflowing  of  the 
erythema  is  likely  to  be  fugitive  and  not  to  obscure  the 
characteristic  distribution  of  the  rash,  in  toxic  cases  there  is 
the  difficulty  that  any  kind  of  erythema  is  liable  to  take  on  a 
special  character  and  to  exhibit  blood-stasis  and  some  degree 
of  blood-staining.  Nevertheless,  even  under  such  confusing 
circumstances  the  identity  of  the  rash  is  seldom  lost,  because 
of  the  special  aggregation  of  purpuric  elements  in  its  pecuhar 
area  of  choice.  This  exact  identification  of  the  purpuric  rash 
is  of  no  little  importance,  because  in  some  cases  of  toxic 
smallpox  the  diagnosis  turns  upon  its  recognition. 

Though  in  many  instances  the  rash  presents  the  striking 
effects  which  have  been  described,  it  must  be  remembered 
that  even  in  toxic  cases  it  more  commonly  displays  the  usual 
characters  of  tint  and  distribution  described  in  Chapter  X. 

It  is  risky  to  found  a  prognosis  on  the  character  of  the 
rash.  Its  association  with  extensive  diffuse  violet  or  purple 
discoloration  is  generally  portentous.  Yet  an  unusually 
vivid  and  deeply-stained  rash  is  sometimes  the  occasion  of  a 
mis-diagnosis  of  haemorrhagic  smallpox  in  the  case  of  a 
patient  who  makes  a  good  recovery  and,  perhaps,  never 
develops  more  than  an  abortive  focal  eruption  and  a  trifling 
secondary  fever. 

Toxic  erythema. — In  some  cases  of  toxic  smallpox  another 
kind  of  rash  is  encountered  which,  unlike  the  purpuric  rash, 
is  devoid  of  any  striking  peculiarity  of  character  or  distribu- 
tion.    It  occurs  as  a  patchy  or  uniform  erythema,  sometimes 


H.^MORRHAGIC    OR    TOXIC    SMALLPOX        99 

limited  to  the  trunk,  sometimes  extending  to  the  limbs  or 
to  the  whole  body.  In  many  cases  the  erythema,  like  the 
erythema  of  the  purpuric  rash,  becomes  the  seat  of  diffuse 
or  blotchy  blood-stains,  especially  when  it  persists  until 
near  the  fatal  termination ;  or,  again,  its  uniformity  may  be 
relieved  by  petechisB.  But  the  display  of  haemorrhage  is  an 
accidental,  not  an  essential  attribute.  In  character,  the  rash 
may  resemble  closely  some  of  those  benign  toxaemic  erythemata 
which  are  most  prone  to  affect  the  trunk  of  the  body. 
(See  Chapter  X.,  p.  70.)  The  points  of  distinction  are  that 
the  toxic  erythema  is  less  fugitive,  is  of  deeper  tint,  is  liable 
to  exhibit  blood-stasis  or  blood-staining,  and  is  apt  to  produce 
a  leather-like  stiffening  or  thickeninsf  of  the  skin  which  it 
occupies,  so  that  the  rash  can  be  felt  as  well  as  seen. 
But,  in  fact,  the  two  kinds  of  rash  are  little  likely  to  be 
confused,  because  they  are  encountered  in  cases  of  so 
different  a  character. 

There  is  more  risk  of  the  toxic  erythema  being  attributed 
to  another  exanthem.  The  interrupted  character  which  it 
frequently  displays  may  be  the  occasion  of  confusion  with 
measles,  as  is  often  the  case  with  the  rose  rashes  described  in 
Chapter  X.  The  severity  of  the  constitutional  symptoms, 
the  insignificance  of  any  symptoms  of  catarrh  which  may  be 
present,  and  the  absence  of  pulmonary  symptoms  are  a 
combination  which  forms  an  important  distinguishing 
feature.  Though  oedema  of  the  lungs  is  common  with  toxic 
smallpox,  this  complication  is  not  of  early  onset,  and  its 
advent  would  be  accompanied  by  other  less  ambiguous  signs 
The  development  of  symptoms  of  haemorrhage,  though  not 
absolutely  precluding  a  diagnosis  of  measles,  should  suggest 
an  attitude  of  extreme  caution. 

A  diagnosis  of  scarlet  fever  may  be  suggested  either  by 
the  toxic  erythema  or  by  the  petechial  rash.  The  mistake  is 
not  very  frequent,  and  there  may  be  no  facts  to  justify  it 
except  the  presence  of  the  rash  itself.  Nevertheless  the  con- 
dition of  the  throat  may  give  colour  to  the  mis-diagnosis.  A 
not  infrequent  symptom  of  toxic  smallpox  is  a  deep  congestion 
of  the  fauces,  palate  and  root  of  the  tongue,  which  gives  place 


100  THE    DIAGNOSIS    OF    SMALLPOX 

quickly  to  a  bloody  extravasation  into  those  tissues.  (Chapter 
XI,,  p.  79.)  There  is,  however,  no  ulceration  of  the  throat, 
no  exudation,  no  enlargement  of  the  tonsils,  no  swelling  of 
the  lymphatic  glands  or  of  the  cellular  tissue  below  the  jaw. 
Though  the  temperature  may  be  high  with  toxic  smallpox, 
not  infrequently  it  is  low ;  whereas  with  scarlet  fever  the  fever 
is  high  except  with  intensely  malignant  cases.  And  vomit- 
ing, which  is  an  extremely  frequent  and  prominent  symptom 
of  scarlet  fever,  is  generally  not  very  pronounced,  and  is  often 
absent  even  in  the  worst  cases  of  smallpox. 

Post-mortem  signs. — The  results  of  the  autopsy  will 
correspond  with  the  signs  of  haemorrhage  observed  before 
death  ;  extravasations  of  blood  along  the  urinary  tract  will  be 
found  when  there  has  been  hsematuria,  congested  lungs  when 
there  has  been  haemoptysis,  gastric  or  intestinal  extravasations 
when  there  has  been  bleeding  from  the  stomach  or  bowel. 
Certain  internal  extravasations  produce  no  symptoms,  and  in 
their  enumeration  it  will  be  presumed  that  only  some  ol 
them  will  be  detected  in  a  particular  case. 

Lungs  and  air-passages. — The  structures  along  the  respiratory  tract ' 
are  liable  to  considerable  damage.  The  pharynx,  tonsils,  palate,  the 
root  of  the  tongue  and  the  epiglottis  may  be  stained  black  by  the 
effusion  of  blood.  The  larynx  and  trachea,  also,  are  often  deeply 
stained.  In  many  instances  the  lungs  are  deeply  congested  throughout ; 
but  sometimes  the  congestion  is  limited  to  their  bases.  In  certain  cases 
distinct  extravasations  are  found  scattered  about  the  lung  tissue,  and 
sometimes  wedge-shaped  pulmonary  "apoplexies"  may  be  seen  on  the 
surface.  In  most  cases  the  tissue  is  not  only  congested  but  also 
oedematous  ;  yet,  as  a  rule,  there  is  no  pneumonic  consolidation. 
Pleuritic  effusion  is  uncommon  and  always  slight ;  but  recent  pleural 
adhesions  are  met  with  with  some  frequency. 

Alimentaty  tract. — The  intestinal  canal  is  much  less  frequently 
affected.  Violet  petechise  and  larger  purple  extravasations  may  be 
found  scattered  about  the  mucous  membrane  of  the  stomach  and  small 
intestine.  Occasionally  the  whole  circumference  of  the  gut  for  a  few 
inches  is  black  from  extensive  extravasation  beneath  the  mucous 
membrane. 

Uriruxrif  organs. — Haematuria  is  associated  with  extravasations  in 
the  kidney  or,  less  frequently,  in  the  bladder.  In  the  bladder  these 
appear  as  black  plaques  upon  the  internal  surface.  In  the  kidney  the 
extravasation  takes  place   beneath  the  lining  of  the  pelvis.      Small 


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H.EMORRHAGIC    OR    TOXIC    SMALLPOX      101 

extravasations  are  met  with  sometimes  on  the  surface  of  the  kidney 
beneath  the  capsule.  Less  commonly  the  whole  organ  is  enlarged  and 
congested. 

Liver  and  spleen. — The  condition  of  the  liver  is  singularly  variable. 
It  is  a  remarkable  fact  that  an  illness  of  about  a  week  in  duration 
should  be  capable  of  increasing  so  greatly  the  weight  of  the  organ.  In 
the  absence  of  any  morbid  change  except  those  found  after  smallpox, 
the  weight  attained  may  be  anything  up  to  6  lbs.  But  in  most  cases 
the  weight  does  not  exceed  4A  lbs.,  and  not  infrequently  it  is  within  the 
normal  limits.  In  some  cases  the  organ  is  much  congested  and,  when 
cut,  drips  with  blood  ;  in  other  cases  the  tissue  is  pale.  The  liver 
exhibits  sometimes  an  early  stage  of  "  nutmeg  "  degeneration.  In  many 
cases  the  tissue  is  unnaturally  yellow  in  colour.  This  colour  is  probably 
due,  in  most  instances,  to  altered  blood-pigment ;  for,  though  fatty 
degeneration  is  found  occasionally,  such  a  change  is  not  very  common. 
Indeed,  the  tissue  is  so  far  from  being  soft,  that  in  most  cases  an 
unusual  toughness  is  its  main  characteristic. 

As  often  as  not  the  spleen  is  within  the  normal  limits  of  size ; 
and  when  it  is  enlarged  the  weight  seldom  exceeds  12  ozs.  The  colour 
and  consistency  are  very  variable. 

Serous  surfaces  and  connective  tissue. — The  serous  surfaces  nearly 
always  exhibit  a  certain  number  of  petechiie  and  small  circular  extrava- 
sations, but  these  are  seldom  very  abundant.  They  occur  in  the 
pleura,  in  the  pericardium  (chiefly  in  the  visceral  layer  near  the  base  of 
the  heart),  and  in  the  peritoneum.  In  the  last  situation  the  favourite 
places  are  along  the  gut  and  in  the  mesentery. 

Extravasations  often  occur  in  the  areolar  tissue  in  various  situations. 
Such  effusions  are  most  apt  to  come  in  the  tissue  about  the  kidneys  and 
along  the  attachment  of  the  mesentery,  and  in  those  situations  are  not 
infrequently  rather  extensive  ;  but  smaller  extravasations  are  liable  to 
be  found  almost  anywhere,  from  the  intermuscular  spaces  to  the  fissures 
of  the  brain. 

Vascular  si/stem. — The  condition  of  the  blood  should  be  noticed. 
In  the  great  vessels  the  blood  is  generally  uncoagulated,  and  in  some 
cases  it  may  be  fluid  even  in  the  heart.  More  often,  there  is  some 
clotting  in  those  cavities,  more  especially  on  the  right  side.  The  clot 
may  be  red,  and  is  often  soft  and  friable ;  but  in  some  cases  a  firm 
white  clot  is  found. 

Diagnosis. — In  this  domain,  so  obscure  and  intricate  and 
so  difficult  of  survey,  it  is  impossible  to  show  an  easy  path 
among  the  pitfalls  and  the  thickets.  But  there  are  a  few- 
useful  landmarks  to  be  recognised. 

Fortunately,  in  most  cases  it  is  not  very  difficult  at  least 
to  identify  the  disease.  Most  patients  survive  until  the  focal 
rash  has  become  a  pronounced  feature  of  the  case ;  and  since 


102  THE    DIAGNOSIS    OF    SMALLPOX 

the  outcrop  of  this  rash  commonly  occurs  at  the  usual  time, 
and  the  rash  has  the  usual  distribution,  the  correct  diagnosis 
will  be  suggested  by  that  distribution,  even  though  the  lesions 
be  anomalous  in  character.  Yet,  since  haemorrhage  may  be 
a  late  or  a  terminal  sign,  the  character  of  the  illness  may  not 
at  first  be  easy  of  recognition,  even  when  the  disease  itself  can 
be  identified.  It  is,  in  fact,  not  an  uncommon  experience 
that  the  gravity  of  the  illness  is  not  realised  until  near  its 
termination.  An  earlier  recognition  will  depend,  often,  upon 
the  appreciation  of  symptoms  less  obvious  than  those  of 
hfemorrhage ;  the  vivid  tint  of  the  rash,  the  softness  of  the 
lesions,  their  tardy  efflorescence  and  evolution,  the  deepening 
collapse  and  the  presence  of  some  of  those  other  signs  which 
were  mentioned  early  in  the  last  chapter. 

The  difficulties  are  most  formidable  in  the  minority  of 
cases  when  the  rash  is  late  in  outcrop,  unusually  deliberate  in 
evolution,  and  atypical  not  only  in  character  but  also,  at  first 
at  all  events,  in  distribution.  The  onset  of  hsemorrhage  and 
its  association  with  a  papular  or  vesicular  eruption  will,  in 
many  cases,  ultimately  suggest  smallpox  But  before  haemor- 
rhage occurs  it  may  be  easy  to  mistake  the  whole  nature  of 
the  disease.  Indeed,  in  some  cases  the  presence  of  the  specific 
lesions  may  be  altogether  overlooked. 

In  all  these  cases,  and  particularly  in  those  in  which  the 
outcrop  is  long  delayed  and  perhaps  anticipated  by  death, 
a  sign  of  inestimable  value,  if  it  is  present  and  can  be  seized, 
is  the  purpuric  rash.  It  comes  early  in  the  illness,  and  its 
frequency  of  occurrence  increases  with  the  severity  of 
attack.  It  is,  therefore,  most  frequent  in  the  cases  of  which 
the  difficulties  of  diagnosis  are  most  profound.  It  is  often 
stated  that  this  rash  is  limited  in  its  distribution  to  the  groins 
and  hypogastrium,  the  so-called  "  genito- crural  triangle." 
Those  who  look  always  for  such  a  limitation  of  the  rash  AviU 
often  miss  it.  But  if  it  be  remembered  that  it  may  have  the 
wider  distribution  which  is  often  seen  in  these  graver  cases, 
and  if  the  vagaries  of  its  character  be  allowed  for,  it  will  become 
of  twice  the  value. 

Another  sign  which  is,  perhaps,  still  more  common,  and 


HEMORRHAGIC    OR    TOXIC    SMALLPOX       103 

for  which  the  observer  should  not  fail  to  seek,  is  enlarge- 
ment of  the  liver.  This,  when  present,  is  easy  of  detection. 
When  the  enlargement  is  considerable,  the  edge  of  the  liver 
may  be  found  as  near  the  umbilicus  as  the  ribs.  But  the 
value  of  the  sign  is  less  conspicuous  than  that  of  the  sign 
last  discussed.  The  symptom  does  not  appeal  to  the  eye, 
and  is  therefore  the  easier  to  miss.  It  becomes  prominent 
later  in  the  case.  It  is  not  pathognomonic  of  smallpox  and, 
unless  the  growth  be  watched,  it  cannot  confidently  be  ascribed 
to  the  current  illness.  Nevertheless,  the  symptom  may  afford 
very  valuable  confirmatory  evidence  in  a  case  of  doubt, 
especially  in  the  cases  of  children  and  young  adults. 

When  the  purpuric  rash  is  absent  and  death  takes  place 
before  the  outcrop,  the  diagnosis  must  rest  heavily  upon  the 
hsemorrhagic  symptoms.  In  these  cases,  happily  not  numer- 
ous, such  diseases  suggest  themselves,  according  to  the  char- 
acter of  the  haemorrhage,  as  diphtheria,  acute  nephritis, 
blood-poisoning.  Diphtheria,  like  scarlet  fever,  is  apt  to  be 
suspected  when  there  is  extravasation  into  the  mucous  mem- 
brane of  the  fauces,  and  diphtheria  is  well  known  to  be 
associated  sometimes  with  hsemorrhagic  symptoms.  But  with 
toxic  smallpox  there  is  never  any  formation  of  membrane. 
"  Blood-poisoning  "  is  the  commonest  mis-diagnosis  in  these 
obscure  cases,  and  many  an  outbreak  of  smallpox  has  been 
traced  back  to  a  case  so  labelled.  So  inexact  a  diagnosis 
may  be  regarded  as  little  more  than  a  confession  of  ignor- 
ance of  the  nature  of  the  illness,  the  fact  being  that 
smallpox  was  never  thought  of  Occasionally  a  case  of 
enteric  fever,  of  ulcerative  endocarditis,  or  of  some  other  dis- 
ease is  certified  as  toxic  smallpox  on  the  strength  only  of 
certain  signs  of  haemorrhage.  In  such  instances  a  know- 
ledge, not  so  much  of  the  hsemorrhagic,  as  of  the  associated 
symptoms  of  toxic  smallpox,  would  go  far  to  shake  the 
erroneous  conclusion. 


CHAPTER    XIY 

ERYTHEMATA  :    SIMPLE  AND  SYMPTOMATIC 

Measles. — More  than  a  thousand  years  ago  the  difference 
between  smallpox  and  measles  Avas  recognised  by  Rhazes,  the 
Persian.  Smallpox,  he  said,  is  ushered  in  by  pain  in  the  back, 
and  its  papules  are  round  and  prominent ;  whereas  the 
papules  of  measles  are  nearly  level  with  the  surface  of  the 
skin.  With  the  latter  disease,  doubtless,  he  grouped  scarlet 
fever  and  other  acute  fevers  distinguished  by  an  extensive 
symmetrical  erythematous  eruption ;  and  since  in  his  writings 
he  constantly  coupled  the  two  names,  it  may  he  questioned 
whether  he  looked  upon  smallpox  and  measles  as  more  than 
different  forms  of  the  same  malady.  However  that  may  be, 
no  adequate  distinction  was  made  in  later  ages,  and  it  was 
not  until  the  time  of  Sydenham  that  smallpox,  measles  and 
scarlet  fever  were  clearly  recognised  as  separate  diseases 
breeding  true. 

Confusion  between  things  so  distinct  is  less  surprising 
when  it  is  remembered  how  vague  was  the  pathology  of  those 
times.  A  disease  was  the  expression  of  a  morbid  tendency, 
or  state  of  the  blood,  which  showed  itself  in  this  way  or  in 
that  according  to  the  idiosyncrasy  of  the  individual,  his 
mode  of  life,  or  so  forth.  In  the  days  when  infectious 
disease  ran  riot,  and  a  pestilence  was  supposed  to  be  as  much 
in  the  order  of  nature  as  an  earthquake  or  a  flood,  accurate 
observations  as  to  the  generation  of  these  fevers  were  not  easy 
to  make.  Smallpox,  like  measles  and  scarlet  fever,  was  then 
a  disease  of  childhood.  And  if  he  began  with  the  assumption 
that  it  depended  upon  the  patient's  complexion,  or  upon  the 
state  of  the  weather,  for  an  erythematous  or  papular  eruption 
to  give  place,  or  not  to  give  place,  to  vesicles  and  pustules,  a 
man  might  live  a  lifetime  and  not  find  out  the  difference. 

IM 


SYMPTOMATIC    ERYTHEMATA  105 

He  might,  like  Rhazes,  detect  a  difference  between  the  soft 
flat  rash  of  measles  and  the  raised  papules  of  smallpox ;  yet 
when  he  observed  other  cases  in  which  a  toxsemic  rash,  to  all 
appearance  like  the  rash  of  measles  or  of  scarlet  fever,  was 
followed  by  a  pustular  eruption,  how  could  he  but  conclude 
that  the  difference  was  unessential  ?  Even  the  distinction 
which  Rhazes  drew  does  not  always  hpld  good.  There  is 
many  a  rash  of  measles  and  many  a  papular  variolous  rash 
which  few  of  us  could  tell  apart.  It  is  such  rashes  which 
now  fall  to  be  considered. 

When  measles  is  mistaken  for  smallpox,  the  patient,  very 
generally,  is  an  adult.  Measles  in  adult  life  is  not  very 
uncommon,  and  the  illness  is  not  insignificant.  That  many 
more  adults  do  not  suffer  is  due  only  to  the  fact  that  most 
have  acquired  immunity  by  a  previous  attack. 

The  symptoms  of  invasion  of  the  two  diseases  are  very 
similar.  With  each  an  interval  of  a  few  days  elapses  be- 
tween the  onset  of  illness  and  the  outcrop  of  the  rash.  In 
selected  cases,  no  doubt,  the  constitutional  symptoms  of  one 
disease  and  the  other  may  show  considerable  divergence  ;  but 
even  pain  in  the  back  is  not  wholly  characteristic,  and  there 
is  hardly  a  combination  of  symptoms  possible  to  one  disease 
which  may  not  be  found  occasionally  with  the  other.  Catarrhal 
symptoms  are  the  most  distinctive  feature  of  measles,  and  if 
these  should  be  very  pronounced  they  would  afford  good 
evidence  in  its  favour.  Yet,  otherwise,  such  symptoms 
would  not  be  of  the  first  value  ;  for  with  smallpox  the  eyes 
are  suffused  and  there  may  be  lacrymation  (Plate  xciv.),  some- 
times the  conjunctiva  is  slightly  injected,  and  there  may  be 
even  a  complaint  of  sore  throat.  The  presence  of  Koplik's 
sign  would  be  of  importance,  but  not  its  absence ;  for  by  the 
time  the  rash  has  become  evident  the  sign  may  have  dis- 
appeared. It  should  be  remembered  that  the  lesions  of 
smallpox  are  very  early  to  develop  on  the  mucous  membrane 
of  the  mouth,  and  may  be  found  sometimes  in  that  situation 
before  the  papules  have  appeared  on  the  skin.  Upon  the 
mucous  membrane  the  lesion  comes  as  a  small  red  soft  spot 
which  soon  becomes  grey.     There  might  be  some  risk  of  con- 


106  THE    DIAGNOSIS    OF    SMALLPOX 

/fusing  Koplik's  spots  with  these  variolous  lesions  but  for  the 
{fact  that  the  latter  have  a  different  distribution,  being  found 
(chiefly  on  the  palate  and  fauces  and  but  to  a  slight  extent,  if 
at  all,  at  the  side  of  the  mouth. 

A  more  telling  point  of  difference  may  lie,  not  so  much 
in  the  character,  as    in    the   intensity  of   the  symptoms   of 
onset.     For   a   patient  with    measles    to    present    a    profuse 
eruption,  he   need   not  be  very  ill   nor  have    an   attack    of 
more  than  average  severity.     (Plate  xcii.)     But  for  a  similar 
rash   to    be    caused    by  smallpox,  the    patient  must  have  a 
confluent  papular  eruption  and  an   exceptionally  severe   ill- 
ness.    If  measles  be  really  the  disease,  this  disparity  between 
the  character  of  the  symptoms  and  the  character  of  the  rash 
may  furnish  significant  evidence  against  the  other.     Patients 
with    confluent    papular    smallpox,  or    those  who   have   an 
exceptionally  severe   toxsemic  fever,   are,  in  fact,  just  those 
who  are  apt  to  exhibit  an  eruption  of  which  the    elements 
approach  closely  in  character  to  those  of  measles.     The  pros- 
tration attending  the  illness   so  alters  the  character  of    the 
rash  that  the  papules  fail  to  convey  that  sense  of  definition 
and  resistance   on  which  the  recognition  of  them  so  much 
depends.    (Chapter  VI.,  p.  40.)  The  papule,  in  such  a  case,  be- 
comes something  like  the  papule  of  measles,  which  is  soft,  lacks 
prominence,  and  merges  imperceptibly  into  the  areola  which 
surrounds  it.    (Plate  xciii.)    The  similarity  is  most  noticeable 
on   the  exposed  parts,  the  face,  hands   and  wrists.     On  the 
face  the  rash  of  measles  may  pass  itself  off  very  well  for  a 
confluent  papular  variolous  rash  of  such  close  texture    that 
the  individual    elements   are   indistinguishable.     About   the 
wrists  the  rash  is   less   likely  to    be  confluent,  but   in  that 
situation  the  papules  are  apt  to  be  exceptionally  prominent 
and  well   defined,  and   not   far    removed  in  character  from 
the  papules  of  smallpox.     Under  such  circumstances  a  hasty 
inspection   of  the   case  is  very    likely  to   convey    a  wrong 
impression ;    but  an  examination  of  other  parts  of  the  skin 
generally  reveals  elements  of  too  discordant  a  character  and 
of  too  indifferent  a  distribution  to  be  consistent  with  such  a 
diagnosis. 


SYMPTOMATIC    ERYTHEMATA  107 

The  real  trouble  comes  earlier,  Avhen  the  rash  is  only 
partly  developed.  On  p.  33  it  was  pointed  out  that  a  papular 
variolous  eruption,  sufficiently  early  in  efflorescence,  has  an 
incomplete  distribution  and  is  limited  to  the  face  and  upper 
part  of  the  body.  That  circumstance  must  be  remembered 
in  differentiating  any  papular  eruption  of  similar  arrange- 
ment. The  fact  is  of  particular  importance  in  the  case  of 
measles,  whose  rash,  like  that  of  smallpox,  begins  at  the 
top  and  spreads  downwards.  In  such  a  stage  of  events  the 
character  of  the  lesions  of  the  two  diseases  may  be  indis- 
tinguishable;  for  variolous  papules  of  only  a  few  hours' 
growth  may  be  quite  as  soft  and  inconspicuous  as  those  of 
measles  of  a  similar  age.  Though  the  identity  of  arrange- 
ment may  be  almost  as  complete,  the  distribution  may 
nevertheless  be  the  most  reliable  guide.  The  rash  of  measles 
is  wont  to  explore  the  parts  round  the  ears,  on  the  fore- 
head, and  among  the  hair-roots,  and  to  display  indifference 
to  the  flexures  of  the  body  and  to  the  bays  and  promontories 
of  the  cutaneous  surface.  (Plates  xxxiii.,  Fig.  2,  xciv.,  and 
xcv.)  Fortunately  the  resemblance  is  fleeting,  and  a  few 
hours  will  change  the  whole  aspect  of  the  rash. 

There  seems  to  be  no  tendency  to  confuse  the  papular 
variolous  eruption  with  measles,  the  mistake  being  almost 
always  in  the  other  direction.  Yet  a  very  large  number 
of  cases  of  smallpox  are  at  first  mistaken  for  measles,  for 
with  the  majority  of  patients  who  exhibit  a  toxaemic  rose 
rash  measles  is  the  preliminary  diagnosis.  The  points  of 
distinction  were  enumerated  in  Chapter  X  (p.  71.).  The  mis- 
conception would  nearly  always  be  avoided  if  it  were  re- 
membered that  an  erythematous  eruption  is  probably  not 
due  to  measles  unless  it  is  associated  with  distinct  symp- 
toms of  catarrh.  It  cannot  be  said  that  the  mistake  is  an 
important  one,  as  it  tends  to  be  so  speedily  corrected.  The 
error  is  more  serious,  though  less  frequent,  when  the  patient 
has  toxic  smallpox  with  a  diffuse  erythematous  toxic  rash. 
The  death  may  then  be  certified  to  be  from  measles,  the  real 
fact  being  disclosed  only  by  the  lamentable  occurrence  of 
secondary  cases.     To  the  remarks  made  in  the  last  chapter 


108  THE    DIAGNOSIS    OF    SMALLPOX 

(p.  99),  it  may  be  added  that  Dieasles  with  htemorrhage 
is  very  rarely  encountered  except  with  young  or  weakly 
children. 

Other  infectious  exanthems. — Scarlet  fever — Rubella. — 
The  toxsemic  rashes  of  smallpox,  which  so  often  suggest 
measles,  occasionally  suggest  scarlet  fever,  but  the  latter 
misapprehension  is  incomparably  the  less  frequent  (pp.  69  and 
72).  A  similar  mis-diagnosis  may  be  caused  by  the  rashes 
of  toxic  smallpox  (p.  99). 

Unlike  that  of  measles,  the  eruption  of  scarlet  fever 
cannot  very  well  be  confused  with  the  papular  variolous  rash. 
But  the  scarlatinal  rash  is  capable  of  being  mistaken  for  a 
toxsemic  eruption,  though  such  an  accident  should  be 
prevented  by  an  examination  of  the  tongue  and  throat  and 
glands.  Rubella,  also,  may  occasion  a  similar  mistake. 
Such  a  misunderstanding  in  the  case  of  either  disease  is 
exceptional,  and  comes  about  by  the  association  of  one  of 
them  with  an  outbreak  of  smallpox.  Smallpox  never  causes 
enlargement  of  the  glands  early  in  the  illness,  and  the 
condition  of  the  tongue  produced  by  it  has  none  of  the 
scarlatinal  characteristics. 

Enteric  fever. — Enteric  spots  have  been  mistaken  for 
variolous  papules  when  the  disease  has  been  latent,  and  the 
rash  unusually  plentiful.  The  enteric  rash  is  somewhat  more 
deceptive  when  some  of  the  lesions,  as  may  be  the  case,  show 
a  tendency  to  become  vesicular.  An  immature  papular 
variolous  eruption,  on  the  other  hand,  has  sometimes  led  to  a 
diagnosis  of  enteric  fever.  Both  accidents  are  exceptional. 
Rose  spots  are  softer  and  less  prominent  than  the  papules  of 
si|iallpox,  and  are  differently  arranged.  Their  choice  is  for 
the  trunk,  and  for  the  chest  and  abdomen  rather  than  the 
back.  It  is  not  uncommon  for  the  spots  to  be  found  upon 
the  thighs ;  but  the  arms  and  legs,  and  above  all  the  face,  have 
little  liability  to  be  affected. 

With  some  cases  of  enteric  fever  it  is  well  known  that, 
besides  or  instead  of  the  usual  exanthem,  purpuric  spots  are 
developed  in  the  skin.  These  may  be  like  flea-bites,  or  may 
be  larger  and  rather  darker  in  tint.     In  such  cases  the  attack 


SYMPTOMATIC   ERYTHEMATA  109 

is  not  necessarily  of  more  than  average  severity.  These 
heemorrhagic  extravasations  occasionally  suggest  a  diagnosis 
of  toxic  smallpox.  Against  that  view  would  be  the  absence 
of  severe  pain,  of  severe  constitutional  disturbance,  and  of 
serious  prostration ;  the  facies  would  be  different  from  that 
of  toxic  smallpox ;  an  enlarged  spleen  would  not  count  for 
much,  but  there  would  be  no  enlargement  of  the  liver ;  and, 
almost  certainly,  there  would  be  no  other  haemorrhagic 
symptom,  and  no  erythematous  rash. 

Typhus. — If  this  were  a  commoner  disease,  or  if  an  out- 
break of  it  were  associated  with  an  epidemic  of  smallpox,  the 
two  things  might  be  more  often  confused.  Occasionally  toxic 
smallpox  is  certified  as  typhus,  but  this  result  arises  from 
deficient  experience  and  not  from  a  real  resemblance  between 
typhus  and  toxic  smallpox  ;  the  patient  has  fever  and  exhibits 
hajinorrhagic  extravasations  into  the  skin,  and  typhus  is 
known  to  be  a  disease  with  which  this  association  is  constant. 
The  fact  is,  when  typhus,  as  often  happens,  fails  to  be 
recognised,  toxic  smallpox  has  no  tendency  to  suggest  itself 
as  a  possible  diagnosis.  On  its  first  appearance  the  rash  of 
typhus  does  not  suggest  hoemorrhage.  It  is  an  erythema,  like 
the  rash  of  measles ;  the  papules  are  pink  or  red,  and  though 
the  colour  may  from  the  first  be  difficult  to  discharge  by 
pressure,  it  is  not  until  later  that  the  spots  become  distinctly 
hsemorrhagic.  The  temptation  with  typhus  is  to  mistake  the 
rash  for  that  of  one  of  the  commoner  exantliems — scarlet 
fever,  or  enteric  fever,  or  measles ;  and  in  the  rare  cases  in 
which  smallpox  is  suspected,  it  is  the  papules  of  discrete  or 
confluent  smallpox  for  which  the  lesions  are  mistaken.  For 
the  misconception  to  arise,  the  papules,  like  those  of  measles 
under  similar  circumstances,  must  be  unduly  firm  and 
prominent.  But  the  distinction  is  very  much  easier  than 
with  measles,  because  the  distribution  of  the  eruption  of 
typhus  does  not  resemble  that  of  a  variolous  rash  at  any  time 
of  its  development ;  it  does  not  begin  on  the  face,  and  in 
many  cases  never  appears  there ;  on  the  contrary,  it  is  apt  to 
appear  early  and  to  be  pronounced  upon  the  abdomen  an^ 
neighbouring  parts. 


110  THE    DIAGNOSIS    OF    SMALLPOX 

Simple  or  unspecific  erythemata. — Simple  purpura. — 
If  the  purpura  of  typhus  can  be  suggestive  of  smallpox,  it 
is  not  surprising  that  the  mistake  should  be  more  frequent 
with  simple  purpura,  a  disorder  so  much  more  frequently 
encountered.  In  such  cases  the  lesions  appear  first  as  pink, 
slightly  elevated,  erythematous  macules,  and  it  is  when  they 
are  in  that  state  that  they  are  deceptive.  The  illness  is  some- 
times attended  by  slight  fever  and  by  some  pain  in  the  limbs, 
a  circumstance  which  adds  force  to  the  suggestion  of  an  exan- 
them.  The  resemblance  does  not  persist,  because  the  colour 
of  the  spots  rapidly  deepens  and  becomes  fixed,  even  if  it  is 
not  imperfectly  mobile  from  the  ^rst.  The  spots,  although 
they  may  be  unduly  prominent  and  form  definite  papules, 
lack  altogether  the  peculiar  firmness  of  variolous  papules. 

Erythema  rheuinaticur)!. — This  malady,  like  simple  pur- 
pura, resembles  smallpox  only  in  exceptional  cases,  the  lesions 
being  generally  of  too  divergent  a  character  to  be  mistaken. 
Yet  the  confusion  arises  less  infrequently  with  this  disorder 
than  with  the  other,  for  the  reason  that  the  papules  are  more 
apt  to  be  firm  and  prominent  and  occasionally  display  a 
tendency  to  become  vesicular.  Some  of  the  lesions  may  be 
very  like  variolous  lesions  of  the  age  of  a  day  or  two,  and  the 
resemblance  is  furthered  by  the  association  of  the  eruption 
with  febrUe  disturbance  and  pain  in  the  joints.  Nevertheless, 
even  if  there  are  no  definite  rheumatic  symptoms  and  no 
grossly  discordant  lesions,  it  is  seldom  that  the  patient  does 
not  exhibit  among  the  rest  some  lesions  which  are  plainly 
purpuric  or  urticarial     (Plate  xcvii.,  Fig.  1.) 

Erythema  nummvlare — Erythema  hullosum. — In  ex- 
ceptional instances  of  mistaken  diagnosis  there  are  to  be 
found  lesions  characteristic  of  erythema  bullosum — round 
erythematous  patches,  as  large  as  a  shilling  or  larger,  sur- 
mounted by  a  large  vesicle.  The  vesicle  may  be  full  and 
tense,  or  flat  and  empty,  and  is  encircled  by  a  red  zone.  If 
the  vesicle  be  flat,  the  pellicle  may  be  of  a  pearl-grey  colour 
throughout,  or  may  be  discoloured  at  the  centre  by  partial 
incrustation  or  by  pigmentation  of  the  skin  below.  When 
such  examples  of  the  malady  are  confused  with  smallpox,  the 


SIMPLE    ERYTHEMATA  111 

confusion  arises  in  spite  of,  and  not  because  of,  the  presence  of 
the  characteristic  lesions,  for  these  are  associated  with  other 
lesions  having  but  a  feeble  resemblance  to  the  prototype. 
These  less  typical  lesions  are  more  plentiful.  They  are 
circular  erythematous  discs  of  smaller  size,  some  or  most  of 
which  display  a  small  central  vesicle.  It  is  more  common  to 
see  cases  in  which  the  characteristic  bullous  lesions  are  absent, 
the  eruption  being  composed  entirely  of  elements  of  the 
character  last  described.  In  other  cases  the  vesicles  are 
altogether  wanting,  and  the  patient  presents  a  crop  of  erythe- 
matous discs  slightly  raised,  like  pink  wafers  stuck  upon  the 
skin.  (Plate  xcvi.)  The  cases  considered  in  this  paragraph, 
in  fact,  form  a  series,  at  the  head  of  which  stand  those  to 
which  the  terms  erythema  bullosum  or  erythema  iris  may  be 
more  aptly  applied.  The  lesions  of  no  member  of  the  series 
have  any  real  resemblance  to  those  of  smallpox,  being  too 
soft  and  superficial. 

All  the  foregoing  varieties  of  erythema  differ  from  the 
variolous  eruption  in  the  circumstance  that  their  favourite 
situations  are  the  limbs,  especially  the  extensor  surfaces, 
while  the  trunk  and,  above  all,  the  face  show  but  little 
liability  to  be  affected.  Thus  erythema  bullosum  and  the 
allied  eruptions  affect  the  extensor  surfaces  of  the  forearms, 
the  legs  suffer  less  often,  and  the  rash  seldom  extends  to  the 
trunk.  Erythema  rheumaticum  is  generally  confined  to  the 
legs;  and  though  the  rash  may  come  on  the  arms  and 
trunk,  lesions  occur  upon  the  face  only  exceptionally.  The 
face  is  the  seat  of  a  simple  purpura  more  frequently,  but 
even  with  that  eruption  the  limbs  are  the  more  favourite 
choice. 

Erythema  rmdtiforTne — Acute  urticaria. — The  generic 
term,  erythema  multiforme,  is  restricted  here  to  some  varieties 
of  erythema  which  differ  in  certain  particulars  from  those 
hitherto  mentioned.  The  eruption,  as  a  rule,  is  more  profuse ; 
it  is  more  catholic  in  its  choice  of  situation  ;  and  from  case  to 
case,  and  even  in  the  same  case,  there  is  more  diversity  in  the 
character  of  the  elements.  It  is  not  necessary  to  insist  on 
these  differences ;  the  classification  of  the  erythemata,  to  a 


112  THE    DIAGNOSIS    OF    SMALLPOX 

great  extent,  is  arbitrary.  But  since  the  circumstance  tends 
to  influence  the  judgment  at  the  bedside,  it  is  well  to  recog- 
nise that  difterent  cases  of  simple  erythema  of  all  kinds,  and 
of  erythema  multiforme  in  particular,  may  have  a  widely 
different  clinical  aspect. 

Among  the  cases  which  are  liable  to  be  mistaken  for 
smallpox  there  is,  naturally,  not  the  same  scope  for  variety  of 
lesion.  The  bulk  of  the  eruption  is  composed  of  papules  or 
macules  comparable  in  poin\  of  size  with  the  lesions  of 
smallpox  or  of  measles.  When  the  rash  consists  wholly  of 
papules  which  are  distinct  and  prominent,  an  event  which  is 
more  likely  to  occur  when  the  rash  is  not  very  profuse,  the 
disorder  may  be  called  erythema  papulatum.  '(Plates  xcviii., 
Fig.  2,  and  xcix.)  More  often,  the  eruption  consists  in  one  place 
of  firm  and  prominent  papules,  in  another  of  soft  flat  lesions 
which,  if  they  are  near  together,  blend  with  one  another  as 
do  the  papules  of  measles.  (Plates  xxxii.  and  xxxiii.,  Fig.  1.) 
In  other  cases,  again,  all  or  most  of  the  lesions  are  of  the  latter 
character.  Sometimes  the  papules  lie  in  a  diffuse  erythe- 
matous matrix,  with  which  in  places,  losing  their  individuality, 
they  may  become  completely  merged.  (Plate  ci..  Fig.  1.) 
Another  difference  from  smallpox  may  not  infrequently  be 
found  in  the  presence  of  a  few  very  large  papules  or  tubercles 
which  would  obviously  be  foreign  to  a  papular  variolous 
eruption. 

A  trait  which  is  particularly  apt  to  engender  suspicion  is 
the  tendency,  which  often  exists,  for  some  of  the  lesions  to 
take  on  an  appearance  as  of  impending  vesiculation.  The 
formation  of  definite  vesicles  with  serous  contents  is  less  com- 
mon, and,  when  it  occurs,  is  generally  slight  in  extent. 
In  very  exceptional  cases,  however,  that  feature  is  con- 
spicuous and  is  displayed  by  a  large  number  of  the  lesions, 
so  that  parts  of  the  surface  may  be  occupied  by  a  vesicular 
eruption,  to  the ,  exclusion  of  the  papular  elements,  (Plates 
xcvii.,Fig.  2,  and  xcviii..  Fig,  1.)  The  vesicles  are  superficial. 
In  other  cases  some  of  the  lesions  become  urticarial,  and  the 
eruption  may  be  described  as  a  compound  of  urticarial  and 
erythematous  papules.     Or  the  rash  may  be  wholly,  or  almost 


SIMPLE    ERYTHEMATA  113 

wholly,  of  an  urticarial  character  and  may  be  called  an  acute 
urticaria.     (Plates  ci.,  Fig.  2,  cii.  and  cm.) 

Aberrations  from  the  variolous  type  of  lesion,  though 
evident  when  sought  for,  may  not  be  very  conspicuous  on  the 
surface  ;  and  at  first  sight  some  of  these  eruptions,  associated 
as  they  are  apt  to  be  with  febrile  symptoms,  may  be  exceed- 
ingly suggestive.  The  aspect  of  the  case  varies  with  the 
profuseness  of  the  rash,  which  may  suggest  a  trivial  or  a 
serious  attack.  As  with  other  forms  of  erythema,  the  inci- 
dence of  the  rash  may  be  chiefly  on  the  limbs;  but  it  is 
frequently  much  more  widely  diffused.  (Plates  c.  and  xxxi.) 
And  not  only  may  the  rash  be  abundant  upon  the  face  but 
the  lesions  may  appear  even  upon  the  palate.  The  order  of 
incidence,  however,  is  seldom  the  same  as  with  smallpox,  and 
as  a  rule  the  diffusion  of  the  eruption  is  incomplete.  All 
varieties  of  the  disorder  run  a  similar  course  and  the  patient 
is  quit  of  his  symptoms  after  a  few  days.  During  involution 
the  rash  loses  all  its  mimetic  qualities. 

Acute  febrile  erytheiiia. — Experience  teaches  that  the 
various  kinds  of  simple  erythema  are  closely  related,  and  sug- 
gests that  the  difference  of  anatomical  character  among  these 
rashes  is  due  as  much  to  personal  idiosyncrasy  as  to  diflfer- 
ence  of  ultimate  cause.  The  several  varieties  which  may  be 
separated  are  to  be  regarded  as  types  only,  and  are  linked 
together  by  many  intermediate  forms.  It  is,  therefore,  not 
to  be  inferred  that  the  cases  grouped  under  the  title  of  acute 
febrile  erythema  are  capable  of  distinct  separation,  pathologi- 
cally or  clinically.  They  are  merely  extreme  examples  of 
erythema  multiforme,  and  are  separated  only  because  it  is  a 
common  custom  completely  to  misinterpret  their  character. 

The  pathology  of  the  Avhole  group  of  simple  erythemata 
is  very  imperfectly  understood.  That  most  cases  are 
rheumatic,  there  is  no  evidence  to  show;  even  with  those 
which  would  be  generally  classed  as  examples  of  erythema 
rheumaticum  the  evidence  of  rheumatism  is  often  incomplete. 
Excepting  those  instances  in  which  the  erythema  is  secondary 
to  an  infection  or  to  the  ingestion  of  a  poisonous  drug  or  a 
poisonous  food,  we  are  in  ignorance  of  the  cause  of  most  of 
I 


114  THE    DIAGNOSIS    OF  .  SMALLPOX 

these  eruptions  and  can  conclude  only  that  they  are  tox?emic. 
That  the  rash  is  an  expression  of  a  toxaemia  is  in  harmony 
with  the  fact  that  it  is  commonly  associated  with  and  often 
preceded  by  febrile  symptoms,  symptoms  which  are  peculiarly 
distinct  in  the  cases  now  to  be  discussed. 

While  it  would  not  be  accurate  to  say  that  with,  cases  of 
erythema  multiforme  the  severity  of  the  constitutional  symp- 
toms is  in  proportion  to  the  abundance  of  the  eruption,  it  is 
a  fact  that  when  those  symptoms  are  unusually  prominent 
the  eruption  is  generally  profuse.  Cases  occur,  by  no  means 
infrequently,  in  which  the  patient  displays  an  eruption  cover- 
ing the  whole  or  the  major  part  of  the  cutaneous  surface,  and 
exhibits  febrile  symptoms  which  are  so  pronounced  as  to  be 
most  suggestive  of  the  onset  of  an  acute  specific  fever.  The 
onset  of  illness  is  distinct  and  may  be  sudden,  and  frequently 
precedes,  perhaps  by  as  much  as  two  or  three  days,  the  out- 
crop of  the  rash.  The  fever  may  be  considerable,  and  the 
temperature  may  reach  103"^,  104°,  or  even  105*^.  The 
patient  feels  ill  and  usually  suffers  from  headache,  which  is 
sometimes  severe,  and  from  pain  in  the  limbs.  With  some 
cases  there  is  nausea  or  vomiting ;  these  symptoms  are 
occasionally  very  prominent,  and  may  be  associated  with 
diarrhoea.  The  tongue  is  furred,  and  the  patient  may  complain 
of  sore  throat,  examination  revealing  injection  of  the  soft 
palate  and  fauces ;  but  sore  throat  is  a  symptom  only  in  a 
minority  of  the  cases.  In  exceptional  instances  the  illness  is 
alarming.  The  fever  runs  high  and  there  may  be  delirium. 
The  patient  is  prostrate,  has  a  dry  tremulous  tongue,  and 
appears  to  be  in  danger  of  succumbing.  Yet,  in  the  author's 
experience,  such  symptoms  are  illusory,  and  all  cases  end 
alike.  Within  a  week  the  symptoms  abate,  the  rash  begins 
to  fade,  and  recovery  is  uninterrupted  and  rapid.  The  follow- 
ing is  an  example  of  a  case  of  moderate  severity. 

N.  D.,  aged  20,  a  gasfitter's  labourer,  previously  in  good  health, 
developed  the  rash  on  the  third  day  of  his  illness.  During  the  first  two 
days  he  had  to  give  up  his  work,  stay  at  home  and  lie  down.  He  had 
pains  in  the  legs,  arms,  and  shoulders,  and  suffered  from  frontal  head- 
ache.    He  was  sleepless  and  lost  his  appetite.     On  the  third  and  fourth 


SIMPLE    ERYTHEMATA  115 

days  of  the  attack  he  complained  of  sore  throat.  He  came  under 
observation  on  the  fourth  day.  He  was  flushed  and  perspiring.  The 
li})S  were  full  and  dry  and  rather  tremulous.  The  tongue  was  moist 
and  covered  with  a  white  fur.  There  was  slight  faucial  injection.  The 
temperature  was  103°. 

There  was  a  discontinuous  erythematous  rash.  This  was  most 
abundant  on  the  limbs,  especially  at  the  distal  ends.  It  was  very  thick 
on  the  backs  of  the  hands,  wrists,  and  feet.  Higher  up  the  limbs,  the 
spots  thinned  out.  The  rash  was  present  on  the  face,  but  not  so 
abundantly  as  on  the  limbs.  It  was  least  abundant  on  the  trunk,  but 
was  as  pronounced  in  front  as  behind.  There  were  a  few  spots  on  the 
hard  palate. 

The  rash  was  dark  red.  For  the  most  part  it  was  made  up  of  small 
round  spots,  many  about  a  quarter-inch  across,  many  smaller.  Most  of 
these  spots  were  slightly  raised.  All  were  soft.  The  resemblance  to 
the  papules  of  measles  in  some  instances  was  very  close.  But  some  of 
the  papules  looked  as  if  about  to  become  vesicular,  and  in  a  few  places 
there  were  small  vesicles  with  serous  contents  lying  on  a  raised  erythe- 
matous base.  In  other  places  the  elements  of  the  rash  were  lost  in  a 
patch  of  diffuse  erythema.  The  hands  and  feet  were  slightly  oedema- 
tous.  On  the  fifth  day  of  illness  the  rash  began  to  fade  and  the  symp- 
toms abated.    The  patient  made  a  speedy  recovery. 


Except  that  they  are  superabundant,  these  eruptions  do 
not  differ  in  their  characteristics  from  those  of  other  forms  of 
erythema  multiforme,  and  they  are  as  easily  separable  from  a 
papular  variolous  rash.  In  many  cases  the  eruption  is  extra- 
ordinarily profuse  and  covers  the  whole  body.  Examples  of 
such  rashes  figure  in  the  plates,  (civ.,  cv.,  cvi.,  and  cvii.) 
Profound  constitutional  disturbance  and  an  abundant  eruption 
covering  face  and  trunk  as  Avell  as  limbs  are  a  combination 
which  is  especially  deceptive;  but  such  universal  eruptions 
can,  at  the  worst,  be  as  easily  separated  by  their  distribution 
as  a  profuse  eruption  of  measles. 

It  is  for  measles,  indeed,  that  acute  febrile  erythema  is 
most  frequently  mistaken,  and  the  plates  will  show  how  close 
may  be  the  resemblance.  Most  patients,  suffering  from  acute 
febrile  erythema,  who  have  come  under  the  author's  observa- 
tion have  been  young  adults,  but  such  patients  have  been 
certified  for  smallpox,  and  most  patients  with  measles  who 
earn  certificates  of  smallpox  are  young  adults  also.  There  is 
no   reason   to   suppose   that  acute  febrile    erythema  has  a 


116  THE    DIAGNOSIS    OF    SMALLPOX 

different  age-incidence  from  other  forms  of  simple  erythema, 
and  therefore  that  there  is  a  distinct  difference  from  measles 
upon  that  score.  The  following  may  be  regarded  as  the  chief 
clinical  distinctions  between  the  two  maladies.  The  interval 
between  the  onset  of  illness  and  the  outcrop  of  the  rash  is 
usually  shorter  with  acute  febrile  erythema,  and  may  be 
altogether  wanting.  The  efflorescence  of  the  rash  generally 
proceeds  differently  with  the  two  diseases  ;  the  eruption  of 
measles  begins  on  the  face  and  spreads  do^v^lwards,  but  with 
the  simple  erythema  there  is  no  such  constant  proclivity.  In 
many  cases,  too,  the  order  of  incidence  is  different,  the  limbs, 
with  the  simple  erythema,  often  suffering  more  than  the  face 
and  trunk  ;  in  some  cases  of  acute  febrile  erythema,  however, 
the  rash  is  so  profuse  that  no  such  difference  is  apparent. 
With  haeasles  it  is  but  rarely  that  there  is  a  tendency  to 
the  development  of  vesicles  or  pseudo-vesicles,  whereas  that 
tendency  is  a  common  feature  of  the  other  eruption.  Again, 
the  rash  of  measles  is  regular  and  uniform,  but  the  simple 
erythema' is  often  irregular  and  multiform.  A  most  important 
and  essential  characteristic  is  the  prominence  of  catarrhal 
symptoms  with  measles.  Though  Avith  the  other  dioorder 
there  may  be  sore  throat,  pronounced  catarrhal  symptoms 
are  almost  always  wanting.  Lesions  which  could  be  mistaken 
for  Koplik's  spots  are  not  found  in  the  mouth  with  simple 
erythema,  but  it  should  be  remembered  that  erythematous 
spots  may  be  found  upon  the  palate. 

The  differential  diagnosis  from  measles  has  been  dis- 
cussed because  it  must  often  have  appeared  to  the  observer 
that  the  choice  in  diagnosis  lay  between  smallpox  and 
measles,  instead  of  between  smallpox  and  a  third  disease. 
A  widely  diffused  erythema,  accompanied  by  febrile  symptoms, 
is  not  necessarily  symptomatic  of  an  acute  specific  fever. 


PLATE   XCn. 


These  two  figures  are  from  the  same  patient,  and  show  the  universal  and  indis- 
criminate distribution  of  the  mature  eruption  of  measles.  From  the  crown 
of  the  head  downwards,  the  rash  overflowed,  surely  and  evenly,  the  whole 
cutaneous  surface. 


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PLATE   XOIV. 

The  patient  had  smallpox,  but  the  disease  was  mistaken  for  measles.  The 
resembbince  was  enhanced  by  the  presence  of  distinct  catarrhal 
symptoms ;  that  the  eyes  were  suffused  and  tearful  may  be  judged 
from  the  print.  Though  efflorescence  was  incomplete,  the  distribution 
more  nearly  resembled  that  of  smallpox.  The  incidence  was  greater 
than  usual  on  the  lower  half  of  the  face,  and  the  rash  was  abundant 
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bust  and  arms  shoidd  be  compared  with  that  pictured  in  the  next 
plate,  which  supplies  a  forcible  contrast  to  this  figure. 


PLATE  XCV. 

From  a  case  of  measles.  The  rash  covered  the  face  and  filled  the  orbits.  It  was  strewn 
equally  over  the  neck,  shoulders,  and  chest.  It  came  indifferently  on  the  ridges  and 
in  the  hollows,  filling  the  supraclavicular  space,  the  supnisternal  hollow,  and  the 
intermammary  groove. 


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PLATE   XCVI. 

In  each  figure  there  is  portrayed  an  eruption  of  erythematous  wafer-like  discs  on  the  back 
of  the  hand  and  wrist.  The  surface  of  the  discs  was  slightly  elevated  above  the  level 
of  the  skin.  In  the  first  case,  at  the  centre  of  almost  every  disc  a  small  vesicle  could 
be  discerned.  In  the  second  case,  with  few  exceptions,  these  vesicles  were  absent. 
^  The  spots  in  this  case  were  notably  smaller  than  in  the  first,  and  therefore  more 
mimetic. 


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Erythema  papulatum  of  extensive  distribution.  The  rash  covered  the  trunk,  limbs,  and  face. 
There  were  apparent  many  diflferences  from  the  distribution  of  smallpox,  but  these 
were  displayed  chiefly  in  points  of  detail. 


PLATE    CI. 

Fig.  1. — Erythema  multiforme.  The  rash  was  confluent  on  the  hands,  and 
simulated  closely  a  profuse  papular  variolous  eruption.  But  in  places,  as 
the  print  shows,  the  individuality  of  the  papules  was  wholly  lost.  The 
general  distribution  of  the  rash  was  very  unlike  that  of  smallpox. 

Fig.  2. — Acute  urticaria.  This  print  and  the  next  (Plate  cii.)  are  from  the 
same  patient.  The  rash  was  generalised,  but,  in  distribution,  showed 
wide  departures  from  the  variolous  pattern.  Tiie  face  was  not  much 
affected,  the  incidence  being  greater  on  the  limbs.  The  rash  was 
thicker  on  the  back  than  on  the  front  of  the  trunk,  but  its  disposition 
was  somewhat  patchy.  The  flexor  surfaces  of  the  limbs  suffered 
equally  with  the  extensor,  and  the  rash  invaded  the  armpits. 


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PLATE   evil. 

Acute  febrile  erythema  in  the  case  of  a  child.  The  rash  was  confluent  on  the 
face,  and  elsewhere  its  elements  were  coherent.  The  resemblance  to 
smallpox  was  closer  at  an  earlier  stage  of  the  illness.  In  the  state  depicted 
the  affinity  was  rather  to  measles,  from  which  the  case  was  distinguished 
by  the  absence  of  symptoms  of  catarrh,  by  the  irregular  and  splash-like 
character  of  the  rash,  and  by  the  large  size  of  its  elements. 


CHAPTER  XV 

CHICKENPOX 

Chickexpox  is  mistaken  for  smallpox  about  half  as  frequently 
as  all  other  diseases  combined.  In  the  majority  of  cases  the 
resemblance  is  superficial  only ;  but  there  are  some  in  which 
the  lesions  approximate  in  character  so  closely  to  those  met 
with  in  many  cases  of  the  graver  disease  that  the  distinction 
would  be  very  difficult,  did  it  turn  only  upon  the  symptoms 
and  upon  the  character  of  the  spots.  Fortunately  the 
eruption  of  each  disease  has  so  much  individuality  of  dis- 
tribution that  it  is  only  when  the  rash  is  scanty,  and  when 
there  is  a  dearth  of  evidence  of  any  kind,  that  the  judgment 
need  be  seriously  in  doubt. 

Chickenpox  is  a  disease  of  childhood,  and  smallpox,  at  the 
present  day,  a  disease  of  adults.  That  to  this  rule  there 
are  many  exceptions  is,  perhaps,  not  fully  realised,  for  many 
adult  patients  are  wrongly  certified.  Chickenpox  is  not 
uncommon  among  adults,  and  occurs  up  to  middle  age ;  and 
adults  get  by  no  means  sparse  eruptions.  (Plates  xxiX-,  ex., 
and  CXI.)  The  disease  is  as  easy  of  recognition  in  their 
cases  as  in  the  cases  of  children  ;  but  not  infrequently  the 
decision  has  rested,  it  would  appear,  not  upon  the  evidence, 
which  was  unambiguous,  but  just  upon  the  mathematical 
probability.  Contrariwise,  smallpox  is  sometimes  mistaken 
for  chickenpox,  not  so  much  from  the  inherent  difficulty  of 
the  case,  as  because  the  patient  happens  to  be  a  child,  and 
chickenpox  a  disease  of  childhood. 

The  method  of  onset  of  the  illness  is  as  insecure  a  guide 
as  the  age  of  the  patient.  The  eruption  of  smallpox  is 
usually  preceded  by  a  period  of  fever,  and  the  fever  of 
chickenpox  is  generally  coincident  with  the  outcrop  of  the 
rasL     Not   infrequently,  however,  the  eruption  of  chicken- 

117 


118  THE    DIAGNOSIS    OF    SMALLPOX 

pox  is  preceded  by  fever  and  malaise ;  indeed,  in  rare  cases 
there  is,  as  is  so  often  the  case  with  smallpox,  a  prodromal 
or  a  coincident  erythema.''^ 

On  the  other  hand,  in  cases  of  smallpox  of  the  milder 
sort  the  outcrop  of  the  rash  may  be  the  first  symptom  to 
be  displayed.  The  presence  or  absence  of  precedent  febrile 
symptoms  is,  in  fact,  not  of  much  account  in  the  class  of 
cases  which  fall  to  be  distinguished.  Nor  is  there  much 
significance  in  the  amount  of  fever  which  accompanies  or 
succeeds  the  efflorescence. 

The  eruption. — Much  weight  should  not  be  attached  to 
the  mere  density  of  the  eruption.  Though  confluent  chicken- 
pox  is  highly  exceptional,  the  rash,  not  infrequently,  is  de- 
veloped in  surprising  quantity,  and  vesicles,  here  and  there, 
may  be  coherent. 

In  most  cases  the  lesions  of  chickenpox  seem  to  begin 
as  vesicles ;  yet,  probably,  such  is  not  really  the  case.  If 
the  rash  be  seen  early  enough,  there  may  generally  be 
observed  among  the  vesicles  some  small  papules,  soft,  hardly 
raised  above  the  surface — for  the  most  part  mere  flecks. 
These  papules  are  so  evanescent  that  the  vesicles  seem  to 
start,  ready  made,  from  the  skin.  Yet  in  some  cases 
the  papules  are  larger,  better  formed,  and  longer  lived. 
The  rash  then  may  be  said  to  pass  through  a  distinct 
papular  stage ;  and  if  the  patient  be  seen  on  the  day  of 
outcrop  he  may  exhibit  a  rash  wholly  papular,  and 
have  an  exceptional  opportunity  of  earning  a  certificate  of 
smallpox. 

Character  of  the  lesions. — The  differential  diagnosis  of 
the  two  diseases  must  almost  always  be  determined  by  the 
evidence  presented  by  the  eruption,  and  the  trend  of  cus- 
tom, perhaps,  is  to  give  undue  weight  to  the  character  of 
the  lesions,  or  rather  to  certain  traits  of  character.  This 
body  of  evidence,  certainly,  is  of  the  greatest  moment,  but 
it  is  necessary  to  keep  the  component  features  in  perspec- 
tive.    Just  as  with  smallpox  the  salient  feature  is  that  the 

•  For  an  account  of  the  accidental  rashes  of  chickenpox,  tee  J.  C.Rolleston, 
British  Medical  Journal,  May  4th,   1907. 


CHICKENPOX  119 

focus  of  the  lesion  lies  deep  among  the  epidermal  cells,  so 
with  chickenpox  it  is  that  the  focus  lies  immediately  be- 
neath the  cuticle.  And  by  as  much  as  either  disease  de- 
parts from  that  rule,  by  so  much  do  its  lesions  approximate 
in  character  to  those  of  the  other. 

That  the  lesions  of  chickenpox  are  rooted  near  the  sur- 
face can  generally  be  made  out  best  by  inspection  and 
manipulation.  The  exceedingly  superficial  and  fragile-look- 
ing vesicles  which  doubtless  suggested  such  names  as  glass- 
pox  and  Windpocken,  though  common  enough  in  practice,  are 
not  often  seen  in  cases  which  are  likely  to  be  misinterpreted. 
Yet,  even  though  the  vesicles  be  somewhat  more  deeply 
placed,  the  distinction  in  position  between  the  lesions  of  the 
two  diseases  is  generally  very  easy  to  appreciate.  (Plate 
cviii.)  Even  when  the  spots  have  dried  up  the  difference 
can  generally  be  perceived  between  the  scabs  of  chickenpox 
adhering  to  the  surface  and  the  counter-sunk  scabs  of  small- 
pox. 

Interpreted,  not  as  a  specific  sign,  but  merely  as  additional 
evidence  of  the  position  of  the  lesion,  there  is  no  objection  to 
regarding  the  absence  of  loculation  in  the  vesicle  as  a  feature 
of  the  disease.  But  it  must  be  remembered  that  a  few 
multilocular  vesicles  are  met  with  sometimes  in  cases  of 
chickenpox,  and  that  unilocular  vesicles  are  not  an  uncommon 
feature  of  smallpox. 

An  interesting  characteristic  of  the  disease  is  the  oval 
outline  which  some  of  the  vesicles  are  apt  to  assume.  The 
vesicle  is  formed  by  the  effusion  of  fluid  beneath  the  horny 
cuticle.  Where  the  skin  is  thrown  habitually  into  iblds  or 
wrinkles  the  cuticle  is  stripped  more  easily  in  the  direction  of 
the  fold  than  across  it,  and  the  vesicle  tends  to  increase  in 
the  one  direction  more  than  in  the  other.  Vesicles  of  this 
shape,  therefore,  are  most  Ukely  to  be  met  with  in  situations 
where  the  creasing  is  pronounced ;  that  is  to  say,  in  the  neigh- 
bourhood of  the  flexures;  and  the  long  diameter  of  the 
vesicle  will  lie  in  the  direction  of  the  crease.  (Plate  cix.) 
A  peculiarity  which  may  be  observed  still  more  fre- 
quently is  that  many  of  the  vesicles  have  not  so  much  an 


120  THE    DIAGNOSIS    OF    SMALLPOX 

oval  as  a  jagged  or  irregular  outline.  (Plate  cviii.,  Fig.  2.) 
The  same  explanation  holds  good,  probably,  for  all  these 
deviations  from  the  circular  shape :  the  resistance  to  the 
expansion  of  the  vesicle  is  different  in  different  directions,  on 
account  of  the  criss-cross  of  lines  and  wrinkles  into  which  the 
skin  habitually  falls. 

That  an  oval  or  irregular  outline  is  less  frequently 
displayed  by  the  vesicles  of  smallpox  is  due,  doubtless,  to  the 
circumstance  that  among  the  deeper  strata  of  the  skin  the 
wrinkling  of  the  surface  would  have  less  influence  in  modify- 
ing the  equal  expansion  of  the  vesicle.  Variolous  vesicles,  at 
any  rate,  are  more  liable  to  depart  from  the  circular  outhne 
when  they  are  unusually  superficial.  (Plate  cviii..  Fig.  1.) 
For  the  reason  that  sometimes  they  do  so  depart,  the 
evidence  irom  outline  must  not  be  pressed  too  far ;  such 
evidence,  indeed,  is  merely  additional  evidence  of  position. 
Yet  an  elongated  outline  to  some  of  the  lesions  is  evidence  of 
chickenpox  which  is  especially  useful  when  the  patient  has 
not  come  under  observation  until  the  lesions  have  become 
encrusted  and  the  other  characteristics  have  become  obscure. 

With  regard  to  all  these  signs  it  must  be  remembered 
that  the  extent  to  which  they  can  be  relied  upon  depends 
upon  the  prominence  which  they  may  attaia  Cases  of 
modified  smallpox  occur,  exceptionally,  in  which  all  the 
lesions,  or  most  of  them,  display  a  character  more  appropriate 
to  chickenpox.  On  the  other  hand,  lesions  of  chickenpox  are 
to  be  encountered  which  are  every  bit  as  deep  as  those  seen 
in  very  many  cases  of  smallpox.  Chickenpox  often  leaves 
scars,  and  what  better  proof  could  there  be  of  the  depth  to 
which  its  lesions  may  penetrate  ?  But  in  cases  of  each 
disease  it  happens  generally  that,  though  in  places  the 
character  of  the  lesions  may  be  discordant,  yet  on  the  whole 
the  trend  of  evidence  is  in  the  right  direction. 

Two  other  minor  characteristics  distinguish  the  eruption 
of  chickenpox :  the  absence  of  umbilication  of  the  vesicles 
and  the  efflorescence  of  vesicles  in  successive  crops,  or,  in 
other  words,  the  presence  of  lesions  in  different  stages  of 
evolution.     A  lack  of  homogeneity  among  the  lesions  must 


CHICKENPOX  121 

not  always  be  expected  of  chickenpox ;  and,  when  it  exists, 
is  not  necessarily  valid  evidence  against  smallpox.  The 
aggregation  of  lesions  of  a  different  age  tells  against  the  latter 
only  under  the  conditions  detailed  in  Chapter  VIII.  (p.  51). 
Indentation  of  a  number  of  vesicles  is  good  evidence  against 
chickenpox,  but  not  the  dimpling  of  a  few.  The  absence  of 
this  sign  counts  nothing  either  way. 

Distribution. — As  there  is  no  part  of  the  body  on  which  the 
lesions  of  smallpox  may  not  appear,  so  there  is  no  part  which 
is  incapable  of  developing  the  vesicles  of  chickenpox.  They 
may  come  on  any  part  of  the  trunk,  limbs,  and  head,  on  the 
palms  and  the  soles,  the  scalp  and  the  ears,  the  palate  and 
the  buccal  mucous  membrane.  Nevertheless,  the  rash,  hardly 
less  than  that  of  smallpox,  shows  its  individuality  by  the 
choice  of  favourite  situations. 

The  seat  of  election  is  the  trunk  of  the  body,  and  the  rash 
may  be  limited  to  that  part  almost  entirely.  More  often  it 
comes  also  on  the  face ;  and  sometimes  is  as  dense  there  as  on 
the  trunk.  (Plates  ex.,  cxi.,  cxii.)  Smallpox  chooses  the 
face  before  all,  next  the  arms,  thirdly  the  back  or  legs. 
While  smallpox  least  affects  the  front  of  the  trunk,  the 
eruption  of  chickenpox  is  often  as  abundant  there  as  on  the 
back,  or  more  abundant.  While  the  variolous  rash  is  more 
abundant  on  the  shoulders  than  over  the  loins,  and  more 
abundant  on  the  chest  than  on  the  abdomen,  that  of  chicken- 
pox  displays  no  such  constant  difference.  Unlike  smallpox, 
chickenpox  tends  to  avoid  the  limbs,  and  if  the  rash  aft'ects 
them,  it  shows  no  preference  for  the  extensor  surfaces.  Its 
density,  besides,  increases  from  below  upwards — the  distri- 
bution is  centripetal ;  whereas  with  smallpox  the  density 
increases,  from  above  downwards — the  distribution  is  centri- 
fugal. The  larger  and  better  developed  variolous  spots  come 
at  the  ends  of  the  limbs  where  the  rash  is  densest ;  with 
chickenpox,  on  the  contrary,  vesicles  which  occur  at  the  ends 
of  the  limbs  tend  not  only  to  be  sparse,  but  also  to  be  small 
and  ill  developed. 

In  applying  these  considerations  to  a  particular  case,  it  is 
necessary  to  weigh  the  evidence  as  a  whole  and  not  to  seize 


122  THE    DIAGNOSIS    OF    SMALLPOX 

upon  one  part  of  it  as  being  essential.  Both  diseases  have 
anomaUes  of  distribution.  In  the  milder  and  more  modified 
cases  of  smallpox,  for  instance,  it  happens  sometimes  that  the 
upper  limbs  or  the  lower  carry  less  than  their  wonted  share 
of  the  rash,  and  that  it  is  disposed  after  a  fashion  which  is 
centripetal  rather  than  centrifugal.  Yet  the  disposition  of  the 
rash  over  the  rest  of  the  body  will  conform  to  the  usual  law.  A 
case  of  chickenpox  may  be  remarkable  because  the  rash  is 
unusually  abundant  on  the  limbs  (Plate  cxiii.);  or  because, 
although  the  rash  is  scanty  on  the  limbs,  a  few  well-developed 
vesicles  or  pustules  are  seen  at  their  extremities,  for  example 
on  the  hands  or  soles.  But  the  presence  of  a  rash  of  some 
density  on  the  limbs,  or  of  a  few  fat  pustules  on  the  hands  or 
soles,  is  by  no  means  inconsistent  with  chickenpox.  Again, 
it  is  unusual  in  cases  of  chickenpox  for  the  rash  to  be  nmch 
denser  on  the  face  than  on  the  trunk  of  tbe  body,  or  for  it  to 
be  much  denser  on  the  back  than  on  the  front  of  the  trunk, 
or  denser  on  the  shoulders  or  on  the  chest  than  over  the  loins 
or  on  the  abdomen.  (Plates  xxix.  and  cxii.)  Yet  those 
events,  happening  singly,  would  not  upset  the  balance  of 
evidence.  Similarly,  smallpox  is  more  apt  than  chickenpox 
to  affect  the  buccal  mucous  membrane  ;  but  with  chickenpox 
a  few  vesicles  are  to  be  encountered  very  commonly  in  that 
situation,  and  occasionally  they  are  present  in  some  abundance. 
It  is  to  be  remembered  that  the  eruption  of  chickenpox 
is  more  liable  than  that  of  smallpox  to  be  unstable  or  capri- 
cious in  distribution.  The  rash  has  affinities,  but  the  bonds  are 
readily  stretched  or  broken.  It  is  less  unusual,  therefore,  for 
chickenpox  to  deviate  so  far  from  the  type  as  to  mimic  the 
distribution  of  smallpox  than  for  a  variolous  rash  to  approach 
closely  to  the  common  pattern  of  chickenpox.  (Plate  cxiii.) 
Occasionally  chickenpox  imitates  smallpox  even  by  responding 
to  cutaneous  irritation.  (Plate  xxxvi.,  Fig.  1.)  Yet,  however 
specious  may  be  the  general  similarity  displayed  by  such 
anomalous  cases,  there  will  be  material  outstanding  difi'er- 
ences.  The  gradations  in  density,  for  instance,  though  right 
in  kind  may  be  insufficient  in  degree ;  the  rash  will  not  be 
shy  of  the  armpits  and  groins ;  nor  will  it  map  out  the  con- 


CHICKENPOX  123 

tours  of  the  surface  on  the  face,  the  neck,  the  bust,  or  on 
other  parts  of  the  body.  (Plates  xxix.,  cxii.,  and  cxiv., 
Fig.  1.)  All  these  points,  which  are  .of  great  importance  to 
the  difterentiation  of  the  two  diseases,  have  been  fully  dis- 
cussed in  earlier  chapters. 

When  the  eruption  is  scanty,  difficulties  in  diagnosis  begin 
to  arise ;  for  then  the  evidence  from  distribution  is  less  com- 
plete. If,  at  the  same  time,  the  lesions  should  be  small  and 
should  have  become  encrusted,  circumstances  under  which 
their  character  may  be  difficult  to  appreciate,  the  trouble 
then  may  be  formidable.  In  such  event,  it  is  probably  safer 
to  be  guided  by  the  disposition  of  the  few  spots  that  can  be 
seen,  than  by  the  character  which  they  may  be  assumed  to 
possess.  (Plate  xxxvi..  Fig.  2.)  It  is  only  in  such  cases  that 
it  is  right  to  be  much  influenced  by  that  circumstantial 
evidence  from  which  it  is  so  difficult  to  turn  the  mind — the 
presence  or  absence  of  either  disease  in  the  neighbourhood, 
the  age  of  the  patient,  and  his  state  in  respect  of  vaccination. 

Summary. — To  conclude  this  account,  the  chief  points  of 
difference  between  the  two  diseases  are  enumerated  in  the 
following  summary : — 

SMALLPOX  CHICKENPOX 

1.  The  rash  is  most  abundant  on  1.  The  abdomen  and  chest  are 
the  face ;  most  scanty  on  the  covered  as  thickly  as  the  face, 
abdomen  and  chest.  or  more  thickly. 

2.  The    rash     is    much     more  2.  The    abdomen     is     covered 
abundant  on  the  back  than  on  the  equally  with  the  back, 
abdomen. 

3.  The  rash  is  more  abundant  3.  The  distribution  is  indif- 
on  the  shoulders  than  across  the  ferent. 

loins,  and   on  the  chest  than  on 
the  abdomen. 

4.  The  rash  favours  the  limbs  ;  4.  The  rash  tends  to  avoid  the 
and,  generally,  the  arms  next  to      limbs. 

the  face. 

5.  The  distribution  on  the  limbs  5.  The  distribution  on  the  limbs 
is  centrifugal.  is  centripetal. 

6.  Therash  favours  prominences,  6.  The  rash  behaves  indiffer- 
and  surfaces  exposed  to  irritation  ;      ently. 

it  tends  to  avoid   protected  sur- 
faces, flexures,  and  depressions. 


124 


THE    DIAGNOSIS    OF    SMALLPOX 


SMALLPOX — continued. 

7.  The  lesions  are  deep-seated, 
and  have  an  infiltrated  base. 

8.  The     lesions    are    generally- 
circular  in  outline. 


9.  The  lesions  are  homogeneous 
in  character ;  or,  if  they  are 
heterogeneous,  they  are  hetero- 
geneous by  law  (Chapter  YIIL, 
p.  52). 

10.  The  vesicles,  generally,  are 
multilocular. 

11.  Frequently  some  of  the 
vesicles  are  indented. 


CHiCKENPOX — con  tinuecl. 

7.  The  lesions  are  superficial, 
and  the  base  is  not  infiltrated. 

8.  The  lesions  frequently  have 
an  irregular  outline  ;  when  they 
lie  near  a  flexure,  they  are  apt  to 
be  oval  or  elongated. 

9.  The  lesions,  often,  are  not 
homogeneous  ;  and  the  want  of 
homogeneity  bears  no  relation  to 
the  sizes  of  the  lesions  and  to  their 
situation. 

10.  The  vesicles,  generally,  are 
unilocular. 

11.  The  vesicles  are  never  in- 
dented and  seldom  dimpled. 


^ 


^ 


PLATE  CVIII. 

In  P'ig.  1  the  lesions  represented  were  those  of  smallpox,  in  Fig.  2  of  chickenpox.  The 
variolous  lesions  were  very  superficial,  and  comparable  in  that  respect  with  Tesicles 
of  chickenpox.  Evidence  of  this  shallowness  of  position  is  indicated  in  the  print  by 
the  steep  edges,  and  by  the  elongated  or  irregular  outline  of  many  of  the  vesicles. 
Those  appearances  were  displayed  still  more  distinctly  by  the  lesions  depicted  in 
Fig.  2,  The  print  illustrates  a  very  characteristic  feature  of  the  vesicles  of  chicken- 
pox,  their  outline  being  very  irregular,  or  sinuous,  or  jagged. 


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PLATE  CXI. 

This  illustration  and  the  next  are  from  photographs  of  the  same  patient.  He 
had  chickenpox,  and  tlie  rash  was  particularly  abundant.  It  was  dis- 
tributed uniformly  and  indifferently  on  the  face,  back,  flanks,  chest,  and 
abdomen  ;  a  plan  of  distribution  in  striking  contrast  with  that  followed  by 
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rasli  diminished  in  density  from  above  downwards,  and  was  as  abundant  on 
the  flexor  surfaces  of  the  limbs  as  on  the  extensor  surfaces. 


PLATE  CXII. 


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indifferently  on  the  face  and  invaded  the  orbit.  It  invaded  also  the  arm- 
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CHAPTER  XVI 

SYPHILIS— VACCINIA 

Syphilis. — This  disease,  which  mimics  all  things,  mimics 
smallpox ;  and  though  it  furnishes  some  of  the  easiest, 
furnishes  also  the  most  difficult  cases  to  distinguish.  In  most 
cases  the  patient  presents  a  papular  or  a  pustular  eruption. 
The  syphilitic  roseola,  as  might  be  supposed,  is  not  often 
mimetic.  Vesicular  syphihdes,  though  uncommon,  might 
reasonably  be  expected,  when  they  do  occur,  sometimes  to 
pass  themselves  off  as  variolous  eruptions;  the  more  so  as 
one  variety  has  been  distinguished  by  the  epithet  "varioH- 
form."  Yet  such  a  tendency  does  not  appear  to  exist,  or  is 
exhibited  but  rarely. 

The  roseola,  the  earhest  of  the  secondary  syphilides,  con- 
sists of  macules  or  erythematous  blotches  scattered,  mostly, 
over  the  front  part  of  the  trunk  and  the  flexor  surfaces  of  the 
limbs.  In  that  guise  it  is,  therefore,  wholly  unlike  a  papular 
variolous  rash,  either  in  character  or  in  distribution.  Yet  there 
are  cases  in  which  the  macules  are  smaller,  more  prominent, 
profusely  developed  and  covering  almost  the  whole  surface 
of  the  body  including  the  face.  If  such  an  eruption  be 
ushered  in  or  accompanied  by  fever  and  febrile  symptoms, 
as  may  very  well  be  the  case,  a  precipitate  observer  might 
suppose  that  he  had  to  do  with  an  acute  specific  fever,  and 
make  a  diagnosis  of  measles  or  of  smallpox.  With  syphilis 
in  the  mind,  it  is  not  difficult  to  detect  the  imposture.  The 
chancre,  it  may  be,  has  only  to  be  looked  for ;  and  commonly 
there  are  not  wanting  other  characteristic  signs.  Smallpox, 
at  any  rate,  can  be  readily  eliminated  by  the  softness  of  the 
lesions,  if  not  by  their  size,  by  their  lack  of  uniformity  of 
character,  and  by  the  anomalies  of  distribution  which  are  no 
less  obvious  when  the  rash  is  profuse  than  when  it  is  scanty. 

125 


126  THE    DIAGNOSIS  OF    SMALLPOX 

With  many  examples  of  papular  and  pustular  syphilo- 
derms  the  rash  is  of  sudden  development,  and,  if  abundant, 
its  outcrop  is  not  infrequently  attended  by  noteworthy  consti- 
tutional symptoms.  It  may  happen,  therefore,  with  these 
eruptions,  as  with  the  roseola,  that  the  general  character  of 
the  illness  may  be  something  after  the  style  of  an  acute  specific 
fever.  In  other  cases  the  facts  are  not  so ;  and  in  all  cases 
the  sequel  differs  from  the  after-history  of  a  case  of  smallpox. 
Yet,  for  reasons  which  will  be  discussed  in  the  next  chapter, 
such  considerations  may  be  of  little  practical  value  at  the 
moment ;  and  though  they  may  find  their  application  in  suit- 
able circumstances,  it  will  not  be  worth  while  to  be  occupied 
with  them  here. 

Of  the  papular  syphilides  some  examples  figure  in  the 
illustrations.  (Plates  cxiv.,  Fig.  2,  cxv.  and  cxvi.)  The  rash 
may  be  profuse  and  may  cover  almost  the  whole  body,  but  its 
incidence  is  frequently  limited  and  it  is  apt  to  be  disposed  in 
patches.  Unlike  the  roseola,  the  papular  syphilide  frequently 
affects  the  face,  and  in  that  respect  resembles  smallpox  ;  but 
there  is  never  a  close  resemblance  in  the  incidence  of  the 
eruptions  of  the  two  diseases.  In  some  cases  the  individual 
papules  approximate  in  character  to  the  variolous  papule ; 
and  if  attention  be  concentrated  on  that  circumstance  to  the 
exclusion  of  other  evidence,  the  fact  may  be  found  deceptive. 
Yet  in  most  cases  distinguishing  characteristics  are  not  want- 
ing to  the  lesions ;  such  as  their  size  or  their  shape — syphilitic 
papules  are  apt  to  be  eccentric  in  outline  and  fiat-topped — 
the  presence  of  scales,  the  colour,  or  the  association  with  such 
exotic  lesions  as  nodules  or  tubercles  or  squames. 

Most  frequently  the  syphiloderm  to  be  distinguished  con- 
sists chiefly  or  entirely  of  pustular  lesions.  (Plates  cxvii. 
and  Lxvi.)  As  with  the  papular  syphihdes,  so  with  the 
pustular,  the  discrimination  is  easy  in  proportion  as  the  lesions 
are  polymorphous.  Sometimes  a  few  discordant  lesions,  like 
ulcers  or  rupial  crusts,  may  be  detected  among  the  rest ;  and 
though  such  pronounced  polymorphism  may  be  absent,  still 
there  may  be  too  much  diversity  of  character.  The  lesions 
of  smallpox  are  not  always  homogeneous;  but  it  would  be 


SYPHILIS  127 

against  such  a  diagnosis  to  find  pustules  and  well-developed 
papules  co-existing,  or  small  pustules  lying  side  by  side  with 
large  crusts.  Again,  some  of  the  pustules  may  be  too  large, 
or  there  may  be  too  much  diversity  of  size,  or  some  of  them 
may  be  too  irregular  in  outline. 

The  position  in  the  skin  which  the  lesion  occupies  is 
important  to  determine,  and  may  be  a  valuable  distinguishing 
feature.  A  syphilitic  sore,  especially  if  it  is  not  lacking  in 
size,  may  dip  do\vn  deeply  into  the  corium  or  even  to  the 
subcutaneous  tissue,  and  may  be  distinguished  by  its  bulging 
shape  and  by  the  induration  about  its  base.  The  presence  ot 
even  a  few  lesions  of  such  a  character  might  be  distinctive. 
Less  frequently,  the  pustule  is  too  superficial,  being  little  more 
than  a  bleb  or  crust  upon  the  surface.  But  most  of  the 
lesions  of  secondary  syphiloderms,  whether  papular  or  pustular, 
occupy  the  papillary  layer  of  the  skin  or  are  embedded  deeply 
among  the  epidermal  cells.  They  occupy,  that  is  to  say,  a 
position  indistinguishable  from  that  of  the  variolous  lesion. 
And  though,  because  the  inflammatory  process  is  less  acute, 
they  may  lack  resistance  to  the  touch  and  feel  softer  than  do 
the  papules  and  pustules  of  smallpox,  yet  of  such  small 
differences  of  resistance  it  is  very  difficult  to  make  sure. 

The  circumstance  that  the  lesions  may  occupy  an  in- 
different position  in  the  skin  causes  some  cases  of  syphilis 
to  be  extraordinarily  difficult  to  distinguish  ;  but  for  the 
difficulty  to  arise  the  rash  must  be  scanty.  When  the 
eruption  is  profuse,  not  only  may  telling  differences  of 
character  be  found  among  the  lesions,  but  abundant  evidence 
will  be  furnished  also  by  their  distribution.  If,  instead  of 
being,  as  is  frequently  the  case,  patchy  or  elliptical  in  its 
incidence,  the  rash  is  broad-cast  and  uniformly  indiscriminate 
in  its  choice  of  situation,  that  lack  of  discrimination  should 
betray  it.  And  should  it  happen,  as  occasionally  it  must,  that 
the  distribution  bears  in  outline  a  specious  resemblance  to  the 
variolous  pattern,  yet  even  then,  unless  the  rash  be  scanty,  it 
will  be  very  easy  to  find  discrepancies  in  points  of  detaiL 

Scanty  pustular  syphihdes  may  be  encountered,  whose 
lesions  are  of  uniform  character  and  do  not  differ  materially 


128  THE    DIAGNOSIS    OF    SMALLPOX 

from  those  of  many  cases  of  modified  smallpox.  To  distin- 
guish such  cases  by  the  evidence  furnished  by  the  eruption 
alone,  it  would  therefore  be  necessary  to  rely  wholly  upon  the 
distribution.  Commonly  the  rash  is  either  of  limited  extent 
or  else  faulty  in  its  order  of  choice.  But  it  is  clear  that 
occasionally  the  characteristics  of  the  eruption  will  be 
indecisive,  and  that  it  will  be  necessary  to  cast  about  for 
other  evidence.  The  patient  may  exhibit  other  symptoms  of 
syphilis,  or  there  may  be  signs  of  previous  syphilitic  eruptions, 
such  as  small  scars  or  pigment-marks.  An  analysis  of  the 
personal  history  may  help,  but  whether  the  disease  be  syphilis 
or  smallpox  it  will  be  equally  unlikely  for  the  constitutional 
symptoms  to  have  been  prominent ;  and  should  the  history 
suggest,  or  should  the  patient  admit,  a  past  attack  of  syphilis, 
it  will  not  follow  necessarily  that  because  he  has  once  had 
syphilis  he  has  not  now  got  smallpox.  Fortunately  the  cases 
are  very  exceptional  of  which  the  difficulties  of  diagnosis  are 
so  profound. 

Vaccinia. — It  is  more  from  the  difficulty  than  the  fre- 
quency of  the  problems  to  which  they  give  rise  that  vaccinal 
eruptions  derive  their  importance.  It  would  seem  that  there 
is  no  temptation  to  attribute  a  vaccina]  rash  to  smallpox 
unless  the  patient  has  been  exposed  to  infection  from  that 
disease.  The  usual  train  of  events  is  that  a  case  of  smallpox 
occurs  in  a  house  and  that  the  inmates  are  successfully 
re- vaccinated ;  after  an  interval  one  of  them  develops  an 
eruption,  and  the  question  then  arises,  is  the  rash  variolous  or 
vaccinal  ? 

Before  passing  to  the  generalised  vaccinal  eruptions,  the 
conditions  produced  by  supernumerary  vaccine-pustules  and 
the  pustules  of  auto- inoculation  deserve  a  word.  It  has  been 
shown  (Plate  i.,  Fig.  2)  that  the  irritation  of  a  successful 
vaccine-inoculation,  done  during  the  period  of  incubation  of 
smallpox,  is  capable  of  producing  a  condition  which  resembles 
closely  that  caused  by  the  development  of  supplementary 
vaccine-pustules  round  the  place  of  original  inoculation. 
The  event  may  happen  in  a  case  of  smallpox  even  when  the 
eruption  is  elsewhere  so  scanty  as  to  concentrate  attention 


PLATE   CXV. 


A  papular  sypbilide.  The  rash  covered  the  whole  body,  and  the  most  distinctive  feature 
of  its  distribution  was  that  all  parts  were  equally  affected — face,  limbs,  back,  chest, 
and  abdomen.  On  individual  parts  of  the  body,  too,  there  was  an  absence  of  those 
contrasts  in  density  which  are  to  be  expected  in  cases  of  smallpox.  All  parts  of  the 
back,  for  instance,  were  equally  affected,  and  the  abdomen  equally  with  the  chest. 


o   >. 

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PLATE  CXVII. 

The  print  represents  a  pustular  syphilide,  and  is  from  the  same  case  as  Plate  Lxvi. 
The  rash  invaded  all  parts  of  the  body,  and  had  a  distribution  not  unlike 
that  of  smallpox.  The  two  plates  show  the  resemblance  in  distribution 
which  was  presented  by  the  eruption  on  the  trunk.  On  the  arms,  however, 
the  rash  had  a  centripetal  distribution,  and  the  flexor  surface  was  affected 
equally  with  the  extensor.  The  rash,  too,  was  present  in  the  groins  and 
armpits.  The  distinction  from  smallpox  was  easily  made  also  from  the 
character  of  the  lesions.  Many  of  them  were  too  large,  and  too  irregular 
in  outline,  and  were  heterogeneous  in  character. 


VACCINIA  129 

almost  exclusively  on  the  arm.  There  may  be  some  simi- 
larity, therefore,  between  a  condition  caused  by  the  conjunc- 
tion of  the  two  causes,  smallpox  and  vaccination,  and  that 
caused  by  vaccination  only  ;  but  it  is  more  likely  for  the 
former  to  be  mistaken  for  the  latter  than  the  reverse.  Vac- 
cinal pustules  of  accidental  inoculation,  occurring  elsewhere 
than  in  the  neighbourhood  of  the  original  sore,  may  be  dis- 
tinguished from  ordinary  variolous  pustules  by  their  irregu- 
larity of  shape  and  of  distribution ;  but  it  may  be  recalled 
that  smallpox  itself  maj'  be  conveyed  accidentally  by  inocula- 
tion, for  example,  from  a  mother  to  the  child.  (Chapter 
VIII.,  p.  53.) 

The  accidental  and  unspecilic  eruptions  which  occur  after 
vaccination  need  not  be  discussed,  nor  the  erythematous 
rashes  of  general  distribution  which  are  doubtless  caused  by 
the  circulation  in  the  blood-stream  of  the  secondary  products 
of  inflammation  absorbed  from  the  vaccine-pustule.  But 
there  are  to  be  encountered  other  generalised  eruptions  which 
are  composed  of  distinct  elements,  and  occasionally  set 
problems  in  diagnosis  which  are  almost  insoluble.  One 
difficulty  of  the  matter  is  occasioned  by  the  rarity  of  such 
rashes.  It  is,  at  least,  to  be  supposed  that  they  are  rare. 
Public  vaccinators  appear  to  have  little  experience  of  them, 
and  the  accounts  in  the  text-books  and  periodicals  are  meagre 
and  unsatisfying.  It  would  not  be  expected  that  vaccinal 
rashes  should  often  be  seen  in  the  receiving-room  of  a  small- 
pox hospital,  but  they  are  seen  by  no  means  so  rarely  as  the 
general  experience  would  lead  one  to  suppose.  Perhaps  the 
truth  is  that  the  rash  is  so  inconspicuous  that  it  escapes 
attention  except  when  the  fear  arises  that  it  may  be 
infectious. 

Wanting  better  information,  generaUsed  particulate  vac- 
cinal rashes  may  be  divided  into  two  groups.  In  the  first 
may  be  placed  those  which  are  composed  of  small  superficial 
papules  (vaccinal  licehn),  or  of  minute  vesicles,  or  of  a  mixture 
of  these  elements.  It  is  probable  that  these  lesions  are  tox- 
a^mic,  and  are  not  evidence  of  a  generalisation  of  the  specific 
virus.  The  subject  is  generally  a  child,  and  the  rash  may  be 
J 


130  THE    DIAGNOSIS    OF    SMALLPOX 

quite  profuse.  The  lesions  are  too  small  and  superficial  to  be 
variolous,  and  there  is  no  tendency  to  imitate  smallpox  in 
distribution.  In  the  second  group  may  be  placed  eruptions 
whose  elements  have  a  closer  resemblance  to  variolous  lesions. 
Ordinarily  the  rash  is  sparse.  The  lesion  may  be  described 
as  a  small  pimple  with  a  vesicular  or  pustular  head,  superficial 
in  position,  but  not  more  so  than  the  more  superficial  of  the 
lesions  which  ma}'^  be  encountered  in  cases  of  modified  small- 
pox. There  is  this  difference,  that  with  modified  smallpox, 
even  with  the  cases  which  are  exceptionally  mild,  some  of  the 
lesions  will  be  more  deeply  placed,  whereas  with  vaccinia 
all  are  superficial.  Yet  there  remains  a  difficulty  :  it  cannot 
be  denied  that  it  is  possible  for  a  variolous  eruption  to  occur, 
very  scanty  and  modified  to  an  exceptional  degree,  all  of 
whose  lesions  shall  be  as  atypical  as  those  of  vaccinia.  And 
assuming  a  particular  case  to  be  an  example  of  smallpox  and 
not  of  vaccinia,  a  highly  modified  eruption  would  be  expected, 
since  the  patient,  by  hypothesis,  would  have  been  successfully 
vaccinated  during  the  period  of  incubation.  Vaccinal 
eruptions  have  been  recorded  which  were  more  abundant, 
and  whose  lesions  were  larger  and  nearer  in  character 
to  those  of  the  modified  variolous  rashes  more  commonly 
encountered.  There  is  no  reason  to  question  the  occurrence  of 
such  eruptions  ;  indeed,  their  occurrence  might  be  expected ; 
but  they  are  undoubtedly  of  the  utmost  rarity,  and  the  author 
has  had  no  experience  of  them. 

Under  such  circumstances,  how  can  it  be  decided  that  the 
patient  has  not  got  smallpox  ?  Since  he  must  be  immune 
both  to  smallpox  and  to  vaccinia,  no  crucial  test  can  be  applied. 
•But  in  some,  at  least,  of  these  cases  the  arrangement  of  the 
lesions  is  not  such  as  might  be  expected  if  the  patient  had 
smallpox.  They  are  prone  to  affect  the  trunk,  and  their 
distribution  is  less  akin  to  that  of  smallpox  than  to  that  of 
chickenpox.  It  is  curious  that  this  should  be  so,  since  it 
seems  probable  that  the  vaccinal  and  variolous  eruptions  have 
the  same  pathology.  Should  no  such  distinct  difference 
appear,  the  case  would  be  best  treated  as  one  of  the  graver 
disease. 


VACCINIA  131 

It  may  happen  that  circumstantial  evidence  opposes  a 
diagnosis  of  smallpox.  If  the  date  of  exposure  to  variolous 
infection  is  known,  that  diagnosis  might  have  to  assume  too 
long  a  period  of  incubation.  If  the  interval  between  the 
exposure  and  the  outcrop  were  more  than  sixteen  or  less 
than  twelve  days,  the  rash  would  be  more  likely  to  be  vac- 
cinal. Or  assistance  may  be  derived  from  the  duration  of  the 
period  between  vaccination  and  the  outcrop  of  the  rash. 
If  the  outcrop  occurred  as  late  as  ten  days  after  the  date  of 
first  reaction  to  the  vaccinal  inoculation,  the  odds  against 
smallpox  would  be  considerable.  But  the  vaccinal  eruption 
is  developed,  generally,  when  the  local  reaction  is  at  its 
height,  that  is  to  say,  at  the  end  of  the  first  week  after  inoc- 
ulation ;  and  such  an  interval  is  too  short  to  preclude  the 
possibility  of  the  eruption  being  the  bloom  of  a  variolous 
infection  previously  ingrained. 


CHAPTER   XVII 

DERMATITIS— PUSTULAR    DERMATOSES 

The  less  frequent  Tnisinterpretations. — Besides  those  der- 
matoses, to  be  noticed  presently,  which  are  capable  of 
assuming  at  least  a  superficial  resemblance  to  the  eruption  of 
smallpox,  there  are  many  others  which  are  mistaken  rarely,  or 
through  accidental  circumstances,  yet  are  of  considerable 
importance  in  the  aggregate. 

In  many  of  these  cases  the  patient  suffers  really  from  a 
constitutional  disorder.  Such  a  misapprehension,  as  might  be 
expected,  occurs  chiefly  when  smallpox  is  rife.  It  may 
happen,  indeed,  and  often  does  happen,  that  the  patient  has 
symptoms  of  illness  but  never  any  eruption ;  he  is  certified  on 
suspicion,  because  he  is  known  to  have  been  exposed  to 
variolous  contagion.  But  we  are  concerned  rather  with  the 
patient  who  is  certified  in  good  faith  because  he  suffers  from 
some  disorder  which  is  associated  with  a  skin-eruption,  but 
associated  by  accident.  It  may  seem  strange  that  such 
diseases  as  acute  rheumatism,  acute  tuberculosis,  or 
pneumonia  should  be  mistaken  for  smallpox.  Yet  to  every- 
one in  practice  it  occurs,  at  the  onset  of  an  acute  disease,  to 
have  to  debate  the  alternative  diagnosis  of  an  acute  specific 
fever.  Suppose,  then,  that  a  close  examination  reveals  the 
presence  even  of  a  few  pimples,  freshly  developed  or  not 
previously  noticed ;  is  it  surprising,  smallpox  being  about, 
that  smallpox  should  sometimes  be  suspected  ? 

In  some  instances  the  eruption  is  really  a  consequence  of 
the  constitutional  disorder,  though  the  disease  is  one  which 
is  not  usually  signalised  by  an  eruption.  The  affection  of 
the  skin  will  be  due,  probably,  to  some  contamination  of  the 
blood-stream.  Thus  the  patient  may  be  suffering  from 
Bright's  disease,  complicated,  perhaps,  by  uraemia ;  or  he  may 

132 


DERMATITIS— PUSTULAR    DERMATOSES      133 

be  a  victim  of  ulcerative  endocarditis  or  of  some  other  form 
of  pysemia.  It  should  not  be  forgotten  that  a  disease  which  is 
peculiarly  liable  to  evoke  a  pustular  skin-eruption  is  diabetes. 
Occasionally  the  patient  is  the  subject  of  a  disease  of  the 
nervous  system,  such  as  acute  mania,  or  cerebral  abcess,  or 
meningitis,  and  the  associated  eruption  may  be  toxaemic  or 
may  possibly  be  trophic.  The  mention  of  the  last  disease 
suggests  that  were  epidemic  meningitis  commoner  the 
eruptions  which  are  a  feature  of  it  might  sometimes  cause  it 
to  be  mistaken.  Another  eruptive  fever  which  perhaps 
owes  to  its  rarity  its  immunity  from  a  similar  misapprehen- 
sion is  glanders. 

On  the  other  hand,  the  patient  may  suffer  from  a  skin- 
disease,  uncomplicated,  one  which  in  general  bears  no  resem- 
blance to  smallpox  and  owes  its  misapprehension  to  accidental 
features  of  its  own  rather  than  to  its  associations  An  erup- 
tion of  small  boils  may  be  associated  with  another  malady ; 
but  sometimes  the  patient  has  no  other  disorder,  and 
suspicion  was  aroused  by  the  suddenness  of  the  attack,  the 
presence  of  febrile  disturbance,  and  the  wide  dissemination  of 
the  lesions.  Though  herpes  zoster  is  unsymmetrical  in 
distribution,  and  therefore  wholly  alien  in  character,  yet  it 
appears  with  some  constancy  in  a  long  series  of  cases  of 
mistaken  diagnosis ;  in  the  deceptive  cases  the  eruption  is 
generally  of  unusual  extent  and  unusual  distribution. 
Another  disease  occasionally  mistaken  is  pemphigus,  the 
accident  being  more  likely  to  occur  when  the  bullae  are 
abnormally  small. 

The  catalogue  is  not  exhaustive,  but  there  would  be  no 
object  in  extending  it.  In  none  of  the  instances  is  there  a 
close  resemblance  to  smallpox,  and  no  great  art  is  required 
for  the  distinction.  The  diagnosis  has  often  been  arrived  at 
by  the  process  of  exclusion.  But  not  all  the  eruptions  to 
which  the  race  is  subject  are  systematised  in  the  text-books  or 
are  within  the  experience  of  any  physician  ;  and  while  it  may 
be  easy  to  assert  that  the  patient  has  not  got  smallpox,  it  may 
be  impossible  to  tell  the  real  disease  from  which  he  suffers. 

Antecedent  symptoms. — In  some  of  the  cases  suggested 


134  THE    DIAGNOSIS    OF    SMALLPOX 

above,  the  observer  has  been  misled  by  the  associated 
symptoms.  It  is  not  well  that,  with  a  pustular  eruption, 
much  weight  should  be  attached  to  these.  When  an  eruption 
is  nascent,  or  when  it  is  erythematous  or  hemorrhagic 
in  character,  the  associated  symptoms,  because  of  the  dearth 
of  evidence,  may  be  of  importance.  But  a  pustular  eruption 
furnishes  evidence  which  far  outweighs  that  which  may  be 
derived  from  other  sources,  and,  unless  they  are  such  as  to  lift 
smallpox  clean  out  of  the  category  of  possible  diseases,  the 
associated  or  antecedent  symptoms  are  of  insignificant  value. 

Even  the  absence  of  antecedent  symptoms  counts  for  little. 
It  will  be  observed  that  many  of  the  dermatoses  presently  to 
be  noticed  are  afebrile.  But  in  most  of  those  instances  the 
eruption  is  not  very  profuse  ;  and  it  is  by  no  means  un- 
common for  scanty  variolous  eruptions  to  be  preceded  by 
toxflemic  symptoms  which  have  been  evanescent  or  wholly 
disregarded.  Of  what  use,  then,  would  it  be  to  instance  as  a 
distinguishing  leature  between  smallpox  and  impetigo,  that 
the  eruption  is  preceded  in  one  case  by  fever  and  con- 
stitutional disturbance  but  not  in  the  other?  Besides,  as 
mentioned  before,  the  association  with  constitutional  disturb- 
ance of  an  eruption,  ordinarily  afebrile,  may  be  accidental.  A 
pustular  syphilide  mayacquire  a  specious  resemblance  to  small- 
pox from  the  onset  of  an  attack  of  influenza,  or  a  drug-rash 
from  the  symptoms  of  the  disease  for  which  the  drug  was  pre- 
scribed. 

Still  more  is  it  the  case  that  merely  the  reputed  absence 
of  antecedent  symptoms  is  of  little  moment.  The  observer, 
often,  has  not  seen  the  patient  until  after  the  development  of 
the  rash  and,  for  the  antecedent  symptoms,  has  to  rely  upon 
hearsay  evidence.  Hearsay  evidence  may  be  involuntarily 
deceptive,  or  it  may  be,  even,  that  there  is  a  deliberate 
attempt  to  deceive.  It  matters  little  whether  the  history 
relates  to  the  absence  of  constitutional  symptoms  or  to  the 
duration  of  the  eruption  itself  It  happens,  not  infrequently, 
that  it  is  not  sufficient  to  exclude  smallpox  that  the  eruption 
is  of  chronic  course.  A  chronic  disease  must  have  a  begin- 
ning, and  may  have  a  sudden  outset ;  but  the  patient,  often. 


DERMATITIS— PUSTULAR    DERMATOSES      135 

has  been  in  possession  of  the  rash  long  enough,  if  all  were 
known,  to  put  smallpox  out  of  count.  The  fact  is  that  the 
circumstantial  evidence  Diay  be  too  strong.  When  smallpox 
breaks  out  in  a  house  or  institution  everyone  with  a 
blemished  skia  is  apt  to  be  looked  upon  with  suspicion.  That 
is  an  attitude  which  cannot  very  well  be  condemned ;  but  it 
follows  that,  in  the  last  resort,  everyone  must  be  prepared  to 
distinguish  smallpox  wholly  by  the  character  of  the  rash. 

Acne. — This  malady  furnishes  a  striking  illustration  of 
some  of  the  preceding  remarks.  It  is  chronic,  afebrile,  de- 
void of  symptoms.  Yet,  next  to  chickenpox,  it  is  perhaps 
the  commonest  disorder  to  be  mistaken  for  smallpox. 

Acne,  as  a  rule,  is  easy  to  identify  by  the  character  of 
certain  of  the  lesions,  and  by  their  limitation  to  the  upper  part 
of  the  body — the  face,  shoulders,  back  and  chest.  (Plate  cxix.. 
Fig.  1.)  The  characteristic  acne-spot  is  deeply  rooted  in  the 
skin  and  its  base  is  infiltrated  and  oedematous,  so  that  the 
contour  of  the  lesion  is  that  of  a  broad  and  shallow  cona 
(Plate  cxviii.)  Such  lesions  are  most  frequent  on  the  upper 
part  of  the  back,  where  they  are  often  associated  with  black- 
heads and  old  scars.  But  most  of  the  spots,  especially  those 
which  occur  on  the  face,  are  more  superficial  and  less 
characteristic,  and  they  may  give  a  passable  rendering  of 
some  of  the  pustules  to  be  found  in  certain  cases  of  modi- 
fied smallpox. 

ThU  worst  cases  are  the  least  likely  to  be  mistaken. 
The  diagnosis  may  be  in  doubt,  either  because  no  charac- 
teristic acne-spots  and  scars  are  present,  or  because  it  is  not 
certain  that  the  patient  has  not  got  smallpox  as  well  A 
close  examination  may  reveal,  indeed,  certain  lesions  which 
could  not  possibly  be  produced  by  acne ;  such  as  vesicles., 
however  small,  for  acne  does  not  produce  vesicles ;  flat- 
topped  or  hemispherical  pustules;  or  disc-like  scabs.  Even 
if  no  such  elements  can  be  detected,  the  presence  of  spots 
on  the  legs  or  forearms  or  hands  would  be  a  highl}'  sus- 
picious circumstance.  On  the  other  hand,  if  the  rash  had  the 
usual  limitation  of  acne,  the  presence  of  a  few  undoubted 
acne-spots  would  almost  certainly  exclude  smallpox;  and  if 


136  THE    DIAGNOSIS    OF    SMALLPOX 

the  character  of  the  lesions  were  wholly  in  doubt,  such  a 
limitation  would  justify  the  exclusion  unless  the  rash  were 
of  the  scantiest  proportions,  that  is  to  say,  composed  of  a 
dozen  or  so  of  spots. 

Dermatitis. — Acute  eczema. — In  the  instances  in  which 
this  disease  is  misinterpreted  the  attack  is  of  sudden 
onset  and  involves  simultaneously  a  large  portion  of  the 
skin.  (Plate  cxix.,  Fig.  2.)  The  patient  may  be  a  child  or 
an  adult,  and  may  or  may  not  have  been  previously  subject 
to  the  malady.  It  may  be,  even,  that  the  disease  w^as 
already  present  in  a  chronic  form  on  a  part  of  the  skin 
affected  by  the  fresh  attack.  (Plate  xxviii.)  It  more  often 
happens,  however,  that  the  disease  has  appeared  for  the 
first  time,  and  has  been  ushered  in  by  fever  and  febrile 
symptoms.  In  some  cases  there  is  the  further  resemblance 
to  smallpox  that  the  eruption  begins  with  the  profuse 
development  of  small  papules,  which  rapidly  become  vesi- 
cular and  pustular.  It  takes  but  a  short  time  for  the  disap- 
pearance of  any  resemblance  which  once  existed,  and  at  no 
stage  of  the  illness  can  the  likeness  be  considered  close. 
The  small  size  of  the  lesions  in  the  majority  of  cases,  their 
superficial  position,  and  the  oedema  and  infiltration  of  the 
skin  below  them,  are  common  distinguishing  features. 

Impetigo. — It  is  not  always  as  easy  as  might  be  supposed 
to  tell  an  impetiginous  eruption.  An  eruption  of  typical 
character,  with  wax-like  vesicles  and  amber-coloured  acfherent 
crusts,  this  there  is  little  temptation  to  confuse.  In  the  more 
troublesome  cases  there  has  been  a  secondary  infection  of  the 
follicles  producing  an  eruption  of  mixed  character,  of  which 
some  of  the  pustules  are  deep-seated  and  may  have  some 
resemblance  to  the  less  typical  variolous  pustules.  Another 
cause  which  tends  to  increase  the  difficulty  of  ultimate 
classification  is  that  the  impetiginous  rash  may  be  secondary 
to  another  form  of  dermatitis.  Yet  the  diversity  of  character 
among  the  lesions  which  may  be  produced  by  these  causes  is 
a  valuable  means  of  distinction  from  smallpox.  Some  of  the 
lesions  may  be  obviously  exotic,  and  a  common  feature  is  that 
they  are  too  heterogeneous.     (Plate  cxxi.,  Fig.  1.)     The  most 


DERMATITIS— PUSTULAR    DERMATOSES      137 

difficult  cases  are  those  in  which  the  rash  is  obsolescent  and 
consists  only  of  crusts.  Something  may  still  be  told  by  their 
shape,  size,  and  position  in  the  skin,  but  the  best  guide  will  be 
their  distribution.     (Plate  cxx.) 

Scabies. — The  vesicular  and  pustular  eruptions  which  are 
secondary  to  scabies  may  be  puzzling  if  their  cause  has  been 
overlooked  or  put  aside.  In  exceptional  cases  the  eruption  is 
profuse  and  widely  disseminated,  and  when  the  subject  is  very 
young  may  even  affect  the  face.  The  burrows  may  be 
difficult  to  find,  but  the  exact  identification  of  the  disease  is 
not  of  much  importance  to  the  issue,  since  it  is  seldom 
difficult  to  exclude  smallpox  by  the  more  salient  features  of 
the  rash.  The  vesicles  evoked  by  the  irritation  of  the  parasite 
are  much  more  superficial  than  those  of  smallpox ;  and  the 
inherent  eruption  is  often  engrafted  with  a  secondary 
dermatitis  which  may  cause,  as  was  mentioned  in  considering 
impetigo,  considerable  diversity  of  character  among  the 
lesions,  and  add  to  the  ease  of  the  distinction. 

Traumatic  dermatitis  and  dermatitis  of  obscure' origin. 
— A  variety  of  cases  may  be  grouped  into  this  section.  As 
with  scabies,  the  rash  may  be  due  to  the  depredations  of 
parasites  or  insects,  such  as  mosquitoes  or  lice.  With  suscept- 
ible subjects  the  bites  of  mosquitoes  sometimes  cause  a  very 
notable  eruption,  which  may  be  attended  by  the  formation  of 
vesicles  as  big  as  a  split  pea.  In  other  cases  the  rash  is  an 
occupation  dermatitis,  or  is  caused  by  some  form  of  mechan- 
ical or  chemical  irritation.  In  some  instances,  though  the 
rash  may  be  suspected  to  be  of  traumatic  origin,  it  may  be 
impossible  to  ascertain  the  precise  cause ;  and  the  observer 
must  be  prepared  to  encounter  examples  of  pustular  dermatitis 
the  cause  of  which  completely  baffles  him.  (Plates  xxvil.  and 
cxxi..  Fig.  2.)  It  by  no  means  follows  that  with  these 
unusual  or  anomalous  forms  of  dermatitis  the  eruption  is 
always  insignificant.  It  may  be  profuse  or  even  confluent. 
Such  cases,  though  disconcerting,  are  the  easiest  to  distinguish 
from  smallpox.  But  commonly  the  rash  is  scanty,  and  its 
only  importance  lies  in  the  fear  that  it  may  be  infectious. 
Each  case  must  be  judged  on  its  merits,  but  it  is  very  seldom 


138  THE    DIAGNOSIS    OF    SMALLPOX 

that  a  variolous  origin  of  the  eruption  cannot  be  exckided  by 
the  peculiarities  of  distribution. 

Lichen  urticatus. — Though  this  disorder  is  essentially  an 
urticaria,  it  may  be  appropriately  mentioned  here,  since  the 
cases  which  simulate  smallpox  do  so  on  account  of  the 
secondary  eruption  of  papules  or  vesicles  to  which  the  urti- 
caria gives  rise.  The  development  of  vesicles  is  a  very 
conspicuous  feature  of  certain  exceptional  cases,  and  the 
eruption  may  be  very  profuse  and  widely  disseminated. 
Lichen  urticatus  occurs  chiefly  among  young  children,  and  it 
might  therefore  be  held  to  simulate  a  highly  modified 
variolous  eruption.  But  the  lesions  are  almost  too  small  and 
superficial  to  support  that  hypothesis,  and  it  is  very  seldom 
that  they  have  sufficient  uniformity  of  character.  The  dis- 
tribution is  wholly  unlike,  and  the  malady,  of  course,  is 
chronic. 

Papular  dermatitis. — Just  as  cases  of  pustular  dermatitis 
are  sometimes  encountered  which  cannot  be  classified,  so  also 
may  the  event  be  similar  when  the  eruption  is  papular  and 
never  advances  beyond  the  papular  stage   of  development. 
The  eruption  may  be  subacute  or  chronic.     The  papules  are 
generally    larger    than   those   commonly   seen   in    cases    of 
papular  eczema,  and  are  not  collected  in  groups,  as  with  that 
disease,  but   are  scattered  broadcast  over  the   surface   as   a 
discrete  and   somewhat  scanty  eruption.     The  incidence  of 
the  rash  is  seldom  universal.     Some  of  these  cases  are  prob- 
ably examples  of  syphilis,  though  no  evidence  of  that  disease 
may    be    forthcoming.      Yet    sometimes    the    subjects    are 
children   in   whose  cases   syphilis   may  almost  certainly   be 
excluded.     Occasionally  a  patient  is   certified   for  smallpox 
who  is  found,  after  a  close  examination,  to  be  suffering  from 
psoriasis.     The  mistake  is  possible  only  when  the  rash  is  in 
the   earliest   stage   of  its  development  and  shows  few  of  its 
special    characteristics.     With    these   cases   of  papular   der- 
matitis it  is  evident  that  time  would  speedily  demonstrate  the 
difference,  but  it  is  generally   possible  to  exclude  smallpox, 
without  delay,  by  the  incompleteness  of  the  difiusion  of  the 
rash  and  the  comparative  softness  of  the  lesions. 


DERMATITIS— PUSTULAR    DERMATOSES      139 

Distribution. — The  enumeration  of  the  members  of  this 
group  might  excite  surprise  that  confusion    Avith   smallpox 
should  often  be  possible.     Yet  the  facts  are  so  ;  and  it  must 
be  remembered  that  exceptional  cases  and  exceptional  cir- 
cumstances may   deceive   even  practised   observers.      What 
makes  the  discrimination  easy  is  not  that  the  eruptions  are 
alien  in  the  character  of  their  elements,  but  that  their  dis- 
tribution is  so  seldom  consonant  with  that  of  the  variolous 
rash.     The  whole  group  of  eruptions  is  characterised  by  a 
partial,  elliptic,  or  patchy  incidence.     Acute  eczema  does  not 
affect  the  whole  cutaneous  surface,  but  certain  portions  of  it 
suffer  for  the  rest ;  the  trunk,  or  the  face,  or  the  flexor  aspects 
of  the  limbs,  or  a  combination  of  these  parts.     Impetigo  is 
often  limited  to  the  face  and  extremities,  and,  when  it  affects 
the  trunk,  the  front  part  suffers  rather  than  the  back,  the  but- 
tocks rather  than  the  shoulders.     Scabies  is  most  likely  to 
affect  the  forearms,  buttocks  and  legs  ;  or  if  the  rash  comes  on 
the  trunk,  the  lower  parts  suffer  rather  than  the  upper ;  the 
face  is  rarely  affected,  and  only  with  children.     The  favourite 
situation  of  lichen  urticatus  is  the  lower  part  of  the  back  and 
the  buttocks ;  though  the  limbs  are  frequently  involved,  the 
face  is  not  so  liable  to  be  attacked.     Dermatitis  from  lice  is 
an  affection  of  the  covered  parts  of  the  body  ;  from  mosquitoes 
of  the  uncovered.     Psoriasis  is  a  disease  of  the  limbs,  not  of 
the  face.     Such   broad  distinctions   are  apparent  in  almost 
every  case,  and,  even   when   the  order  of  incidence   is   not 
dissonant,  discrepancies  in  points  of  detail  are  not  far  to  seek. 
Drug-rashes. — The  only  drugs  which  need  be  considered 
are   the   bromide   and   iodide   salts,  both   of  which   produce 
eruptions  having  similar  characteristics.     The  lesion  begins 
as  a  soft  papule  or   as  an   erythematous   macule   or  blotch. 
Presently  a  vesicle  is  formed,  which  rapidly  becomes  pustular 
and  then  encrusts.     Though  alike  pathologically,  the  eruptions 
encountered   in   different   cases  may   be   of  very   dissimilar 
appearance.     The  lesions  may  be  of  almost  uniform  size,  and 
may  not  differ  materially  in  size  and  shape  and  in  their  course 
of  evolution  from  those  of  smallpox  or  of  chickenpox ;  but 
disparity  of  size  is  sometimes  a  conspicuous  feature,  and  most 


140  THE    DIAGNOSIS    OF    SMALLPOX 

or  all  of  the  pustules  may  be  a  good  deal  larger  than  those 
of  smallpox  and  may  bear  a  closer  resemblance  to  those  of 
pemphigus.  Another  cause  which  contributes  to  the  diversity 
of  character  among  different  cases  is  that  the  tendency  to 
suppurate  is  not  always  so  manifest;  the  evolution  of  the 
lesions  is  then  more  protracted,  and  they  display  an  incli- 
nation to  the  development  of  weak  granulation-tissue,  so  that 
lesions  of  an  acneiform  or  fungoid  character  are  produced. 
Such  lesions  are  more  characteristic  of  bromide  rashes. 
Whatever  may  be  their  precise  character,  the  pustules  are 
generally  superficial  in  situation  and  occupy  a  position  in  the 
skin  nearer  to  that  of  the  lesions  of  chickenpox  or  of  im- 
petigo ;  but  that  characteristic  is  not  invariably  pronounced. 
The  rash  is  symmetrical,  but  is  apt  to  be  elliptic  in  distribution 
and  is  very  frequently  patchy,  so  that  it  may  be  confluent 
in  one  place  and  sparse  in  another.  It  may  be  profuse  or 
altogether  scanty. 

These  variable  characteristics  conduce,  on  the  whole,  to 
facility  of  discrimination  from  smallpox,  and  the  majority  of 
cases  cannot  very  well  be  confused  with  that  disease.  But  it 
is  not  always  so.  Plate  xxvii..  Fig.  1,  gives  a  good  idea  of 
the  kind  of  lesion  which  may  have  to  be  distinguished,  though 
in  that  J)articular  case  there  was  no  evidence  to  show  that  the 
rash  was  produced  by  the  administration  of  drugs.  An 
eruption  composed  of  lesions  of  such  a  character,  but  more 
widely  diflfused,  might  require  for  its  separation  an  intimate 
knowledge  of  the  characteristics  of  variolous  lesions  and  of  the 
manner  of  their  arrangement.  Given  such  knowledge,  drug- 
rashes  can  be  differentiated  from  smallpox  nearly  always  with 
ease  and  certainty.  In  point  of  fact  they  are  not  confused  so 
frequently  as  might  be  supposed  ;  but  that  circumstance  is 
probably  due  less  to  inherent  dissimilarity  than  to  the  fact 
that  the  connection  between  cause  and  effect  is  in  most  cases 
kno^vn  to  the  observer.  If  it  is  not  known  what  drugs,  or 
that  any  drugs,  have  been  administered,  the  exact  identifi- 
cation of  the  rash  may  be  impossible  and  there  may  be  some 
scope  for  the  exercise  of  the  imagination. 


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PLATE  CXXI. 

Fig.  1. — Pustules  of  impetigo.  The  print  shows  that  the  lesions  were  irregular  in  outline 
and  heterogeneous  in  kind.  On  the  arm  small  pustules  could  be  seen  lying  among 
larger  lesions  which  had  become  incrusted. 

Fig.  2. — Pustular  dermatitis  in  the  case  of  a  cachectic  boy.  The  rash  was  uneven  in  its 
incidence.    The  bulk  of  it  was  on  the  buttocks ;  a  few  spots  were  scattered  on  the 

/  legs,  arras,  and  elsewhere. 


CHAPTER    XYIII 

VACCINATION    AS    A    FACTOR    IN    DIAGNOSIS 

The  last  piece  of  evidence  to  collect  is  the  condition  of  the 
patient  relative  to  vaccination.  This  should  seldom  be 
allowed  to  outweigh  direct  evidence  as  to  the  nature  of  the 
disease,  but  there  are  times  when  it  is  very  pertinent. 

The  common  tendency  is  both  to  underestimate,  and  to 
exaggerate  the  capacity  of  vaccination  to  protect  against 
smallpox.  Within  limits  that  capacity  is  incapable  of 
exaggeration.  A  person  successfully  vaccinated  or  re- 
vaccinated  acquires  for  a  time  an  immunity  so  complete  that 
a  deliberate  attempt  to  acquire  smallpox  would  surely  fail. 
But  with  some  persons  such  an  absolute  immunity  is  rela- 
tively fleeting,  and  within  a  few  years  will  have  become 
sufficiently  attenuated  for  an  attack  of  smallpox  to  be 
acquired,  though  generall}'  but  an  insignificant  attack. 

The  briefest  possible  duration  of  absolute  immunity  after 
vaccination  or  revaccination  may  be  taken,  for  practical 
purposes,  to  be  two  years.  If  a  patient,  suspected  of  having 
smallpox,  could  furnish  undoubted  evidence  of  a  successful 
vaccination  within  such  a  period,  the  evidence  against  small- 
pox would  be  overwhelming.  With  most  persons  the  duration 
of  absolute  immunity  is  more  protracted.  A  few  people 
acquire  a  life-long  immunity  after  infantile  vaccination; 
many  persons  after  one  successful  revaccination.  In  rare 
instances  immunity  is  still  impermanent  after  several  success- 
ful  revacCinations.  Should  the  patient  display  conclusive 
evidence  of  successful  vaccination  within  five  years,  or  of 
successful  revaccination  within  ten,  the  weight  of  that 
evidence  would  be  against  his  having  smallpox.  It  need 
hardly  be  said  that  unsuccessful  vaccinations  do  not  count.^ 

*  The  fact  would  be  diflScult  of  proof,  but  it  is  probable  that  the  duration  of 
his  vaccinal  immunity  bears  some  relation  to  the  subject's  inborn  susceptibility, 

141 


142  THE    DIAGNOSIS    OF    SMALLPOX 

In  the  application  of  these  considerations  much  import- 
ance will  attach  to  the  kind  of  rash  which  the  patient  exhibits. 
With  a  child  of  five,  vaccinated  in  infancy,  supposing 
the  diagnosis  to  lie  between  chickenpox  and  smallpox,  the 
evidence  would  tell  against  smallpox  if  the  pustules  were  fat 
and  the  rash  abundant :  if  the  rash  were  scanty  and  the 
pustules  small,  the  evidence  would  be  more  equally  balanced, 
even  assuming  on  other  grounds  an  equal  probability  of  either 
disease ;  for  though  on  the  one  hand  a  variolous  eruption  in 
the  case  of  a  young  vaccinated  child  would  almost  necessarily 
be  scanty  and  modified,  on  the  other  hand  the  probability  of 
complete  immunity  to  smallpox  would  be  considerable.  If 
the  child  were  unvaccinated,  the  fact  that  the  rash  was 
abundant  and  the  lesions  well  formed  would  count  nothing 
either  way  unless  the  rash  were  actually  confluent ;  but  if  the 
spots  were  small  and  scanty  the  disease  would  probably  be 
chickenpox.  Exceptions  will  occur  now  and  then  in  both 
directions.  An  unvaccinated  child  may  be  insusceptible  by 
nature,  and  may  get  an  attack  of  modified  smallpox.  On  the 
other  hand,  in  rare  cases  the  protection  of  vaccination  or  of 
revaccination  suffers  complete  erosion  within  five  years,  and 
the  subject  might  then  be  vulnerable  even  to  an  attack  of 
confluent  or  of  toxic  smallpox. 

In  such  inquiries  it  is  important  to  have  authentic 
evidence  of  the  success  of  the  vaccination  and  of  its  date. 
With  children  the  matter  is  simple  enough.  The  scars  of 
primary  vaccination  never  become  obliterated  until  after  the 
lapse  of  a  good  many  years.  The  success  of  a  reputed  revac- 
cination is  more  difficult  to  determine.  The  statements 
of  patients  are  unreliable  to  the  last  degree.  Scars  of  suc- 
cessful revaccination  are  often  transitory,  and  sometimes  the 
inoculation,  though  undoubtedly  successful,  leaves  no  scar. 
It  may  be  difficult  to  decide,  also,  whether  the  existing  scars 
are  all  infantile  or  are  in  part  due  to  revaccination.  If  the 
vaccination  was  recent,  the  scars  will  be  pigmented.  But 
it   must    be   remembered    that   a  pigmented    area,   though 

and  that  a  person  naturally  resistant  to  smallpox  would  be  likely  to  acquire  by 
vaccination  complete  immunity  of  long  duration  ;  and  so  conversel}'. 


YACCINATION    IN    DIAGNOSIS  143 

not  a  scar,  may  remain  for  months  after  an  unsuccessful 
inoculation.  A  pigmented  or  a  pink  scar  may  be  taken 
as  good  evidence  that  a  successful  vaccination  has  been 
done  within  two  years,  and  therefore  that  the  patient  is  in- 
susceptible. 

Even  at  the  time  of  vaccination  it  is  often  difficult  for  the 
operator  to  decide  whether  or  not  he  has  obtained  a  success- 
ful reaction.  In  cases  of  primary  vaccination  it  is  different, 
but  everyone  is  familiar  with  the  atypical  reactions  which 
may  be  obtained  after  re  vaccination.  Operators  are  some- 
times too  easily  satisfied.  Though  a  typical  vesicle,  or  indeed 
a  vesicle  of  any  kind,  must  not  always  be  expected,  it  is  a 
great  mistake  to  accept  as  valid  evidence  of  success  an 
ambiguous  inflammatory  reaction.  Localised  redness  and 
swelling  of  the  skin  under  the  seat  of  inoculation  frequently 
follow  an  unsuccessful  operation,  and  unfortunately  such 
reactions  are  sometimes  accepted  as  vaccinal.  Such  an 
erroneous  assumption  may  be  productive  of  the  most  serious 
risk  to  the  subject.  It  has  happened  many  times  that  a 
person,  certified  to  have  acquired  protection  from  recent 
vaccination,  has  been  proved  shortly  afterwards  to  be  sus- 
ceptible to  a  characteristic  vaccinal  reaction,  a  result  which 
would  have  been  impossible  had  the  first  operation  been 
successful.  When  the  operation  is  undertaken  on  account  of 
exposure  to  infection  of  smallpox,  a  similar  mistake  may  cost 
the  patient  dearly.  Short  of  a  definite  vesicle,  the  only 
evidence  which  should  be  accepted  as  indicative  of  success  is 
a  circumscribed,  deep-seated,  indurated  swelling  of  the  skin 
under  the  seat  of  inoculation,  developing  about  three  days 
after  the  operation ;  and  such  a  result  should  be  confirmed 
by  at  least  one  subsequent  inoculation. 

If  a  person  has  been  shown  to  be  really  insusceptible  to 
vaccinia,  that  fact  is  proof  positive  that  he  is  insusceptible 
to  smallpox."^  The  test  is  of  importance  when  there  is  a 
suspicion  that  a  mild  and  unrecognised  attack  of  smallpox 

*  The  converse  proposition  does  not  necessarily  hold  good,  that  susceptibility 
to  vaccinia  proves  previous  susceptibility  to  the  infection  of  smallpox  conveyed 
through  the  usual  channels. 


144  THE    DIAGNOSIS    OF    SMALLPOX 

has  been  sustained  by  a  person  who  has  not  previously  been 
vaccinated.  The  validity  of  the  deduction  rests  upon  the 
assumption,  which  for  practical  purposes  may  be  accepted  as 
true,  that  no  one  is  born  insusceptible  to  vaccinia."'^ 

Vaccination  after  exposure. — Germane  to  this  subject  is 
the  effect  of  vaccination  done  after  exposure  to  infection. 
Vaccination,  done  within  a  day  or  two  after  exposure  and 
followed  by  a  normal  reaction,  is  a  certain  preventive.  If 
postponed  until  the  latter  part  of  the  period  of  incubation  it 
will  be  ineifectual. 

The  duration  of  the  period  of  incubation,  counting  to  the 
outcrop  of  the  rash,  may  be  taken  as  fourteen  days.  If  this 
period  be  divided  into  three  intervals  comprising  seven  days, 
three  days,  and  four  days,  then  it  will  be  accurate,  in  the 
main,  to  say  that  a  successful  vaccination  done  in  the  first 
interval  will  wholly  prevent  the  attack,  done  in  the  second 
will  have  more  or  less  effect  in  modifying  the  eruption,  and 
done  in  the  last  will  merely  add  to  the  patient's  troubles. 

But  to  this  rule  there  are  occasional  exceptions.  A  patient 
may  be  vaccinated  successfully  as  early  as  the  fourteenth,  or 
even  fifteenth,  day  before  the  outcrop  and  yet  not  escape  the 
disease ;  or  during  the  first  half  of  the  incubation-period  and 
yet  develop  an  unmodified  attack.  The  fact  is,  that  the 
pertinent  date  is  not  when  the  subject  is  vaccinated,  but 
when  the  reaction  begins.  Sometimes,  through  a  peculiarity 
either  of  the  lymph  or  of  the  subject,  the  reaction  which 
should  be  manifest  on  the  third  or  fourth  day  does  not  begin 
to  arise,  it  may  be,  until  a  week  or  more  after  inoculation. 
In  such  a  case  the  rise  of  immunity  will  be  correspondingly 
deferred.  It  is  for  this  reason  that  protection  against  small- 
pox can  never  be  promised  confidently  if  its  acquisition  be 
postponed  until  after  exposure. 

In  another  class  of  cases  the  exception  is  more  apparent 
than  real.     Infants,  newly  born  of  variolous  mothers,  may 

*  Infants  bom  of  variolous  mothers  are  sometimes  insusceptible  to  vaccinia, 
and  possibly  the  successful  vaccination  of  the  mother  shortly  before  the  birth 
of  the  child  may  have,  occasionally,  a  similar  effect.  But  there  is  reason  to 
suppose  that  in  either  case  the  immunity  conferred  upon  the  child  is  fugitive. 


VACCINATION  145 

develop  smallpox  even  though  vaccinated  immediately  after 
birth.  This  circumstance  is  due  to  the  fact  that  the  infection 
has  been  derived  from  the  mother  in  utero.  The  rash  in 
such  cases  is  developed  within  ten  days  of  birth,  and  the 
vaccination  has  in  reality  been  done  during  the  period  of 
incubation. 

Except  by  reason  of  accidental  failure,  vaccination  can 
be  performed  successfully  at  any  time  during  the  greater  part 
of  the  period  of  incubation.  But  after  the  onset  of  illness 
immunity  develops  rapidly,  and  after  the  efflorescence  is 
completed  the  patient  is  wholly  insusceptible  to  vaccinia. 
There  is,  however,  a  fallacy  to  beware  of  in  determining  the 
success  of  a  vaccinal  reaction  when  the  operation  has  been 
done  during  the  period  of  incubation.  The  irritation  of  the 
inoculation,  even  though  the  operation  be  unsuccessful,  may 
be  sufficient  to  evoke  presently  a  small  cluster  of  variolous 
vesicles  over  the  seat  of  inoculation.  The  appearance  pro- 
duced is  then  very  similar  to  that  of  a  successful  vaccinal  re- 
action, and  may  be  by  no  means  ea.sy  to  distinguish  from  it. 

A  chart  is  reproduced  to  show  how  immunity  to  vaccinia  is 
acquired  coincidently  with  the  onset  of  an  attack  of  small- 
pox.* 

For  its  construction  the  records  were  collated  of  a  large 
number  of  patients  who  suflPered  from  smallpox,  and  had  been 
vaccinated  either  during  the  period  of  incubation  or  during 
the  tirst  few  days  of  the  illness.  The  percentage  of  successful 
results  was  then  plotted  on  verticals,  corresponding  to  the 
intervals  which  elapsed  between  the  dates  of  vaccination  and 
of  outcrop.     (Chart  xiv.) 

From  this  chart  it  is  clear  that  a  very  good  final  test 
against  smallpox  would  be  furnished  by  the  successful  vacci- 
nation of  a  patient  with  an  eruption  of  doubtful  character. 
If  the  eruption  were  three  days  old  or  more,  the  evidence 
might  be  regarded  as  conclusive.  But  it  will  be  observed  that 
a  successful  vaccination  done  on  the  day  of  outcrop  would  not 
be  entirely  convincing. 

•  f  Compiled  from  the  hospital  records  by  the   author's  former  colleague. 
Dr.  R.  M.  Freer. 


146 


THE    DIAGNOSIS    OF    SMALLPOX 


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Chart  xiv. — Immunity  to  Vaccinia  acquiked  coincidently  with  the 
ONSET  OF  Smallpox. 


The  data  used  for  the  construction  of  the  beginning  and  of  the  end  of  the 
chart  are  not  completely  accurate.  Done  during  the  first  few  days  of  the  period 
of  incubation,  successful  vaccination  generally  prevents  the  attack,  and  there- 
fore would  eliminate  from  the  records  the  cases  of  persons  so  protected.  In 
effect,  the  proportion  of  successful  results  among  inoculations  done  during  the 
first  two-thirds  of  the  period  of  incubation  may  be  assumed  to  be  uniform  and  to 
approach  closely  to  one  hundred  per  cent. ,  the  few  unsuccessful  results  being 
due  merely  to  accident.  On  the  other  tand,  after  the  outcrop  of  the  rash  the 
percentage  of  successful  results  obtained  was  really  much  less  than  would  appear 
from  the  chart.  This  fact  is  due  to  the  circumstance  that  the  records  were  not 
made  for  the  purpose  of  these  deductions.  Unsuccessful  vaccination  after  the 
outcrop,  in  an  undoubted  case  of  smallpox,  is  of  no  clinical  interest,  and  in 
man)'  cases  the  fact  was  not  recorded.  The  line  of  susceptibility  should  fall 
near  to  the  base-line  on  the  first  day  of  eflflorescf-nce,  and  become  extinguished 
on  the  third.  One  successful  reaction  was  recorded  for  the  fourth  day,  but  waa 
open  to  question. 

SMALLPOX  AFTER  A  PREVIOUS  ATTACK 

A  patient  who  has  once  had  smallpox  is  generally  insus- 
ceptible to  a  second  attack.     But  second  attacks  are  not  rare, 


SECOND    ATTACKS  147 

though  they  are  much  more  uncommon  than  reputed  second 
attacks.  Many  patients  with  smallpox  assert  a  previous 
attack,  but  furnish  no  evidence  in  support  of  the  statement. 
In  most  of  such  cases  the  historical  illness  was  probably 
chickenpox.  Even  when  the  patient  is  scarred,  there  is  often 
no  more  than  a  presumption  that  the  scars  are  variolous. 
When  the  evidence  of  the  first  attack  is  trustworthy,  it  will 
be  found  almost  invariably  that  the  interval  between  the  two 
attacks  has  been  a  long  one  and  that  the  second  attack  is 
mild.  Instances  in  which  a  patient,  displaying  undoubted 
evidence  of  a  previous  attack,  dies  of  confluent  or  of  toxic 
smallpox  are  excessively  rare.    ' 

If  reputed  second  attacks  are  to  be  looked  upon  with  a 
critical  eye,  what  of  relapses  and  recurrences  ?  Many  such 
are  on  record.  But  the  burden  of  proof  which  is  on  the 
recorder  is  a  little  too  lightly  borne.  Nature  is  not  prodigal 
of  her  prodigies ;  and  each  of  us  may  with  confidence  regard 
such  an  incident  in  his  practice  as  furnishing  presumptive 
evidence  of  one  error  of  diagnosis. 


INDEX 


Abortion,  78. 

Abscesses,  a  sequela  of  smallpox,  56. 

Acne,  135  ;   lesions  of,  31,  135. 

Acute  febrile  erythema,   113. 

Adenitis,  100,  108. 

Air-passages,    haemorrhage    affecting, 

78,  79  ;   morbid  pathology  of,  100  ; 

the  eruption  in,  20. 
Albuminuria,  91. 
Alimentary  tract,  morbid  anatomy  of, 

100. 
Areola  of  lesion,  27. 
Arms,  distribution  on,  13,  15,  16,  19. 
Attire,  influence  of,  on  distribution,  6. 

Birdwood  on  the  pathology  of  small- 
pox, 8. 

Blebs,  surrounding  variolous  lesions, 
53. 

Blood,  changes  with  toxic  smallpox, 
101. 

Blood-poisoning,  a  mis-diagnosis  in 
cases  of  toxic  smallpox,  103. 

Boils,  a  sequela  of  smallpox,  56  ;  mis- 
taken for  smallpox,  133. 

Boot,  irritative  effect  of,  7,  11. 

Bright's  disease,  103,  132. 

Broncho-pneumonia,  a  cause  of  death, 
39. 

Bruises,  75,  78. 

Catarrh,  60,  71 ;  with  acute  febrile 
erythema,  114,  116  ;  with  measles, 
105. 

Cerebral  disease,  mistaken  for 
smallpox,  133. 


Chickenpox,  117  et  seq.  ;  age-inci- 
dence of,  117  ;  distribution  in  the 
case  of,  121  ;  irritation -patches 
with,  24,  122  ;  lack  of  homogeneity 
among  lesions  of,  51,  120  ;  papules 
of,  118  ;  position  in  skin  of  lesions 
of,  31,  119,  120;  pre-emptive 
period  of,  117;  prodromal  rashes 
with,  118  ;  shape  of  vesicles  of,  63, 
119. 

Clinical  cases  with  symptoms  of 
haemorrhage,  79. 

Collapse,  with  toxic  smallpox,  87,  91. 

Collar,  irritative  effect  of,  7. 

Confluent  eruptions  modified,  45. 

papular  eruption,  40  ;    measles 

mistaken  for,  106. 

smallpox,  33  et  seq.  ;   aspect  of 

patient  with,  36;  recession  of 
pyrexia  with,  36 ;  suppura- 
tive fever  with,  38  ;  termina- 
tion in  cases  of,  39  ;  toxaemic 
fever  with,  33,  63. 

vesicular  eruption,  41,  42. 

Conjimctiva,    haemorrhage    into,    78 ; 

injection  of,  60,  71,  105. 

Connective  tissue,  extravasations  in, 
with  toxic  smallpox,  101. 

Corsets,  effect  of,  on  distribution,  7, 
19. 

Crusts,  27,  54;  of  chickenpox,  119; 
of  impetigo,  136 ;    rupial,  126. 

Curschmann  on  toxic  smallpox,  85. 

Cutaneous  stimulation,  effect  on  dis- 
tribution of  exposure  to  and  pro- 
tection from,  9,  10 ;  with  chicken- 
pox,  122. 


149 


150 


INDEX 


Delirium,  with  the  secondary  fever, 
39  ;  with  the  toxaemia,  60  ;  with 
toxic  smallpox,  87. 

Dermatitis,  o  medicamentis,  139 ; 
papular,  138 ;    traumatic,  137. 

Desquamation,  55. 

Diabetes,  133. 

Diarrhoea,  with  acute  febrile  erythema, 
114. 

Diphtheria,  103. 

Discrete  smallpox,  39. 

Distribution,  6  et  seq.  ;  anomalies  of, 
18  ;  faulty,  or  lack  of  gradation  in, 
22 ;  general  scheme  of,  14 ;  in- 
fluence of  attire  on,  6 ;  influence 
of  exposure  to  or  protection  from 
cutaneous  stimulation  on,  9,  10  ; 
of  acne  lesions,  135 ;  of  chicken- 
pox  rashes,  121  ;  of  drug-rashes, 
140  ;  of  eruption  of  measles,  107  ; 
of  eruption  of  typhus,  109 ;  of 
immature  rash,  23,  33  ;  of  meagre 
rashes,  25  ;  of  pustular  dermatoses, 
139;  of  simple  erythemata.  111, 
113,  115  ;  of  syphilitic  rashes,  125  ; 
of  toxaemia  petechial  rashes,  67 ; 
of  toxaemic  rose-rashes,  70 ;  of 
vaccinal  rashes,  130  ;  on  the  ear, 
17  ;  on  the  face,  14,  16 ;  on  the 
foot  and  hand,  11  ;  on  the  neck, 
17  ;  on  the  trunk  and  limbs,  15, 
18,  19 ;  on  the  scalp  and  air- 
passages,  20. 


Ear,  distribution  on,  17. 
Eczema,  acute,  136. 
Endocarditis,  ulcerative,  103,  132. 
Enteric   fever,    108 ;     purpura   with, 

103,  108. 
Epistaxis,  78. 
Eruption,  see  "  Rash." 
Eruptions,  see  "  Rashes." 
Eruptive  fever,  33  et  seq. 
Erythema,  acute  febrile,  see  "  Acute 
febrile  erythema." 

bullosum,  110. 

iris,  111. 


Erythema  multiforme.  111 ;  and  acute 
febrile  erythema,  113;  with 
formation  of  vesicles,  112; 
with  urticarial  lesions,  112. 

nummulare,  110. 

papulatum,  112. 

rheumaticum,  110. 

Erythematous    toxsemic    rashes,    see 

"  Toxaemic  rose-rashes." 
Eyes,  affections  of,  complicating  small- 
pox, 56;  suffusion  of,  60. 

Face,  distribution  on,  14,  16. 
Facial     expression,     with     confluent 

smallpox,  36  ;  with  toxic  smallpox, 

86. 
Fauces,    congestion    of,    with    toxic 

smallpox,  79,  99,  103. 
Felix  on  the  pathology  of  smallpox, 

8. 
Focal  lesion,    definition    of,    2 ;      of 
smallpox,  see  "  Lesion." 

rashes,  see  "  Rashes." 

Fcetor  with  toxic  smallpox,  90. 
Foot,  distribution  on,  11. 
Freer     on     immunity     to     vaccinia 
developing  with  the  onset  of  small- 
pox, 145. 

Garter,  irritative  effect  of,  7. 
Glanders,  133. 
Granulomata,  48,  55. 

Haematemesis,  79. 

Haematuria,  79. 

Haemoptysis,  79,  92. 

Haemorrhage,  post-toxaemic,  74 ;  af- 
fecting the  pustules,  75. 

,  toxaemic,  75  ;  about  the  lesions, 

76,  77,  95  ;  conjunctival,  78  ; 
cutaneous,  76 ;  from  the 
gums,  79 ;  from  the  kidneys, 
79  ;  from  the  lungs,  79,  92  ; 
from  the  stomach  and  bowel, 
79  ;  nasal,  78  ;  orbital,  78  ; 
symptoms  of,  with  toxic 
smallpox,  96  ;   uterine,  78. 


INDEX 


151 


Haemorrhagic  smallpox,  see  "  Toxic 
smallpox." 

symptoms   of   smallpox,    73    et 

seq.  ;  cases  illustrative  of,  79  ; 
pathology  of,  74. 

Hand,  distribution  on,  12,  19. 

Headache,  of  toxaemia,  59 ;  with 
acute  febrile  erythema,  114 ;  with 
toxic  smallpox,  86. 

Heart-failure,  87,  91. 

Hebra  on  the  alleged  identity  of  small- 
pox and  chickenpox,  1. 

Herpes  zoster,  133. 

Heterogeneous  eruptions,  51  ;  of 
chickenpox,  51,  120  ;  of  impetigo, 
136;  of  scabies,  137;  of  syphilis,  126. 

Hyperpyrexia,  with  toxic  smallpox, 
89. 

Immunity,  due  to  previous  attack  of 
smallpox,  146  ;  due  to  vaccination, 
44,  63,  141  ;  natural  and  acquired, 
43 ;  to  vaccinia  acquired  coinci- 
dently  with  the  onset  of  smallpox, 
145  ;  to  vaccinia  implying  insus- 
ceptibility to  smallpox,  143. 

Impetigo,  136. 

Incubation-period,  61. 

Influenza,  59. 

Initial  rashes,  see  "  Toxsemic  rashes." 

Intrapustular  haemorrhage,  75. 

Intrauterine  infection,  84,  97,  145. 

Intravesicular  haemorrhage,  77. 

Irritation-patches,  6 ;  pathology  of, 
7  ;  with  chickenpox,  24,  122  ;  with 
other  exotic  eruptions,  24. 

Kidneys,  morbid  anatomy  of,  100. 
Koplik's  spots  in  diagnosis,  106,  116. 

Lacrymation,  60. 

Leg,  distribution  on,  15,  19. 

Lesions  (variolous),  aberrant,  30,  41, 
95  ;  areola  of,  27  ;  blebs  surroimd- 
ing,  53  ;  characteristics  of  modified, 
47  ;  evolution  of,  retarded  by  tox- 
aemia, 42,  94  ;    granuloma -like,  48, 


55 ;  histology  of,  28 ;  in  cases  of 
toxic  smallpox,  41,  95;  involution 
of,  27  ;  life-history  of,  26 ;  of  in- 
oculation, 53  ;  obsolescent,  54  ; 
position  of,  31  ;  shape  of,  31,  52  ; 
size  of,  27,  52. 

Lichen,  vaccinal,  129  ;  urticatus,  138. 

Limbs,  distribution  on,  15,  19. 

Liver,  enlargement  of,  91,  103 ; 
morbid  anatomy  of,  101. 

Loculation  of  vesicle,  28  ;  absence  of, 
with  chickenpox,  119. 

Lumbar  pain,  59,  86. 

Lungs  and  air-passages,  morbid 
anatomy  of,  100. 

Malleoli,  distribution  on,  12. 

Mania,  60  ;  acute,  mistaken  for  small- 
pox, 133. 

Measles,  104  et  seq.  ;  catarrhal  symp- 
toms of,  60,  105,  116  ;  diagnosis  of, 
from  acute  febrile  erythema,  115; 
distribution  of  immature  rash  of, 
23, 107  ;  rash  of,  resembling  papular 
variolous  eruption,  40,  106,  107 ; 
resembling  toxaemic  erythema,  71, 
107 ;  resembling  toxic  erythema, 
99,  107. 

Melaena,  79. 

Melancholia,  60. 

Meningitis,  59,  133. 

Menstruation,  in  cases  of  smallpox,  78. 

Mental  symptoms,  with  the  toxaemia, 
60  ;   with  toxic  smallpox,  87. 

Modified  smallpox,  43  et  seq.  ;  char- 
acteristics of  lesions  of,  47  ;  defin- 
ition of,  43 ;  diagnosis  of,  48 ; 
diagnosis  of,  from  vaccinia,  130; 
influence  of  vaccination  in  relation 
to,  44,  144  ;  in  mild  epidemics,  49  ; 
in  toxic  cases,  93  ;  pathology,  43, 
44  ;  suppurative  fever  of,  39,  46 ; 
with  confluent  eruption,  45 ;  with 
eruption  incompletely  modified,  46. 

Morbid  anatomy,  100. 

Morbilliform  toxaemic  rash,  see  "Tox- 
aemic rashes." 

Mucous  membrane  of  mouth  and  air- 


152 


INDEX 


passages,  distribution  on,  20;  haem- 
orrhage affecting,  78,  79 ;  morbid 
anatomy  of,  100. 

Muscular  atony  with  toxic  smallpox, 
86. 

Mustard-leaf,  irritative  effect  of,  6. 

Neck,  distribution  on,  17. 
Nephritis,  103,  132. 

Odour  of  toxic  smallpox,  90. 
CEdema  of  the  lungs,  79,  91,  100. 
Outcrop    of    eruption,    23,    33,    61  ; 

delayed  in  toxic  cases,  94. 
Outline  of  lesions,  of  smallpox,   52, 

120  ;   of  chickenpox,  52,  119. 

Pain,  with  acute  febrile  erythema, 
114;  with  the  toxaemia,  59;  \*'ith 
toxic  smallpox,  86. 

Papules,  formation  of,  26  ;  of  chicken- 
pox,  1 18  ;  size  of,  27  ;  tactile  im- 
pression of,  29 ;  see  also  under 
"  Lesions." 

Pathology  of  smallpox,  7. 

Pemphigus,  133. 

Period  of  incubation,  61. 

Petechise,  76  ;  with  enteric  fever,  108  ; 
with  toxic  smallpox,  97. 

Petechial  or  purpuric  toxaemic  rash, 
see  under  "  Toxaemic." 

Pigmentation,  55,  75. 

Pleurisy  with  toxic  smallpox,  100. 

Pneumonia,  mistaken  for  smallpox, 
59,  132 ;   with  toxic  smallpox,  92. 

Post-mortem  signs  of  toxic  smallpox, 
100. 

Post-toxaemic  haemorrhage,  74. 

Pre-emptive  period,  61,  94 ;  with 
chickenpox,  117. 

Prodromal  rashes,  see  "  Toxaemic 
rashes." 

Proptosis  of  eyeball,  78. 

Prostration,  59 ;  with  acute  febrile 
erythema,  114;  with  toxic  small- 
pox, 86. 

Protopapules,  53. 

Psoriasis,  138. 


Purpura,  simple,   110:    with  enteric 
fever,  103,  108. 

variolosa,  85,  footnote. 

Pustular  dermatoses  associated  with 

certain  constitutional  disorders,  132, 

133. 
Pustules,  formation  of,  27  ;    size  of, 

27  ;    sec  also  under  "  Lesions." 
Pyaemia,  133. 
Pyrexia,  with  acute  febrile  erythema, 

114;    with  chickenpox,  117;    with 

scarlet  fever,  100  ;    with  smallpox, 

33  et  seq.  ;   with  the  toxaemia,  59 ; 

with  toxic  smallpox,  87. 

Rash,  focal  (of  smallpox),  confluent, 
see    "  Confluent     smallpox "     and 
.  "  Confluent    eruptions  "  ;     desqua- 
mation caused  by,   55 ;    diagnosis 
of  when  meagre,  25 ;    discrete,  see 
"  Discrete     smallpox  "  ;     distribu- 
tion of,  see  "  Distribution  "  ;  evolu- 
tion of,  35,  52 ;    in  toxic  cases,  41, 
77,  95  ;   involution  of,  39  ;  matura- 
tion of,  36;    modified,  see  "Modi- 
fied  smallpox  "  ;     obsolescence   of, 
54 ;    of  aberrant  character,  30,  41, 
95 ;     of    heterogeneous    character, 
51 ;    outcrop  of,  see  "  Outcrop  "  ; 
pigmentation    following,    55,    75 ; 
scars  caused  by,  54  ;   see  also  under 
"  Lesions." 
Bashes,  exotic,  irritation-patches  with, 
24;     their    distinction    from 
smallpox,  by  distribution,  21 
et  seq.,  when   immature,   23, 
when   lacking    in    gradation, 
22,  when  meagre,  25. 

,   focal   and  toxaemic,  definition 

of,  2  ;    occurring  with  small- 
pox, 3. 

,  septic,  56. 

,     toxaemic,     of     smallpox,     sec 

"  Toxaemic  rashes." 

,    toxic,    97 ;    see    also    "  Toxic 

erjrthema." 
Relapses  and  recurrences,  147. 
Revaccination,  evidence  of  successfuli 


INDEX 


153 


142,   143  ;    immunity  acquired  by, 

141. 
Rheumatism,  acute,  59,  132. 
Rolleston     on    accidental    rashes    of 

chic  ken  pox,   118. 
Rose  rashes,  of  smallpox,  see  "Tox- 

aemic  rashes." 
Rose-spots,  of  enteric  fever,  108. 
Roseola,  syphilitic,  125. 
Rubella,  108. 

Salivation,  60. 

Scabies,  137s 

Scabs,  27,  54;  of  chickenpox,  119; 
of  impetigo,  136  ;    of  syphilis,  126. 

Scalp,  distribution  on,  20. 

Scarlatiniforra  toxaemic  rash,  see 
"  Toxaemic  rashes." 

Scarlet  fever,  69,  71,  99,  108. 

Scars,  54. 

Second  attacks  of  smallpox,  146. 

Secondary  fever,  4,  37. 

Seeds,  54. 

Septic  absorption,  a  cause  of  death, 
39. 

rashes,  56. 

Serous  surfaces,  morbid  anatomy  of, 
101. 

Sleeplessness  with  the  toxaemia,  60. 

Spleen,  enlargement  of,  91  ;  morbid 
anatomy  of,  101. 

Subcutaneous  haemorrhage,  75,  78. 

Subvesicular  haemorrhage,  77. 

Suffusion  of  eyes,  60. 

Sweat,  influence  of,  on  distribution,  7. 

Syncope  with  toxic  smallpox,  87,  91, 
92. 

Syphilis,  125  et  seq.  ;  distribution  in 
the  case  of,  125,  126  ;  papular  and 
pustular  rashes  of,  126,  127  ;  poly- 
morphic character  of  lesions  of,  51, 
126  ;  position  in  skin  of  lesions  of, 
31,  127  ;  roseola  of,  125  ;  vesicular 
rashes  of.  125. 

Temperature,  «ee  "  Pyrexia." 
Toxaemia,  variolous,  symptoms  of,  3, 
5S  ;   temperature  with,  59. 


Toxaemic     and    suppurative     fevers, 
inter-relation  of,  63. 

haemorrhage,  75. 

petechial  or  purpuric   rash,  67, 

97  ;  diagnosis  of,  69 ;  diag- 
nostic value  of,  in  cases  of 
toxic  smallpox,  102 ;  dis- 
tinction of,  from  rash  of  scarlet 
fever,  69,  99,  108;  effect  of, 
on  incidence  of  focal  rash, 
69. 

rashes,  definition,  2 ;  variolous, 

3,  66  et  seq. 

rose-rashes,      70 ;       distinction 

from  rash  of  measles,  71,  107, 
from  rash  of  scarlet  fever,  71, 
108,  from  rubella,  108,  from 
toxic  erythema,  99. 
Toxic  erythema,  98  ;  distinction  from 
measles,  99,  107,  from  scarlet 
fever,  99,  108,  from  toxaemic 
rose-rash,  99. 

rashes,  97. 

smallpox,     albuminuria      with, 

91  ;  cases  illustrative  of,  80  ; 
character  of  focal  rash  of,  41, 
77,  95  ;  constitutional  symp- 
toms of,  85  ;  date  of  death 
from,  94 ;  definition  of,  73  ; 
diagnosis  of,  101  ;  distinction 
from  enteric  fever,  109,  from 
measles,  99,  107,  from  scarlet 
fever,  99,  108,  from  typhus, 
109  ;  duration  and  course  of, 
93  ;  enlargement  of  the  liver 
with,  91,  103;  evolution  of 
eruption  delayed  with,  93  ; 
facies  of,  86  ;  foetor  with,  90  ; 
haemorrhagic  symptoms  of,  76, 
96 ;  heart-failure  with,  87, 
91 ;  in  the  case  of  a  new-bom 
infant,  84,  97  ;  mental  sjrmp- 
toms  of,  87  ;  morbid  anatomy 
of,  100  ;  oedema  of  the  lungs 
with,  79,  91  ;  outcrop  post- 
poned with,  94 ;  pyrexia 
with,  87  ;  recovery  from,  92  ; 
termination  of,  91  ;  with 
modified  focal  rash,  93. 


154 


INDEX 


Trunk  and  limbs,  distribution  on,  15, 

18,  19 ;    with  chickenpox,  121. 
Tuberculosis,  acute,  132. 
Typhus,  109. 


Ulcerative  endocarditis,  103,  132. 
Umbilication  of  vesicle,  32  ;   spurious, 

32  ;    with  chickenpox,  120. 
Underclothing,  irritative  effect  of,  7. 
Uraemia,  132. 
Urinary  organs,  morbid  anatomy  of, 

100. 
Urticaria,  acute,  113  ;  with  erythema 

multiforme,  112. 
Uterine  haemorrhage,  78. 


Vaccination  after  exjxjsure  to  infec- 
tion, 144  ;  after  the  onset,  145  ;  as 
a  factor  in  diagnosis,  141  et  scq.  ; 
effect  of,  in  modifying  the  eruption, 
45, 144 ;  evidence  of  successful,  142 ; 
influence  of,  on  numerical  severity 


of  attack,  44 ;  provocative  of 
irritation-patch,  6,  128,  145. 

Vaccinia,  \28  etseq.  ;  auto-inoculation 
of,  129  ;  distribution  in  the  case  of, 
130  ;  generalised,  129  ;  resembling 
modified  smallpox,  130 ;  super- 
numerary pustules  of,  128. 

Varicella,  see  "  Chickenpox." 

Variola  hsemorrhagica  pustulosa,  85^ 
footnote. 

sine  eruptione,  63. 

Vascular  system,  morbid  anatomy  of, 
101. 

Vesicles,  formation  of,  26  ;  loculation 
of,  28  ;  of  chickenpox,  31,  53,  119  ; 
size  of,  27  ;    umbilication  of,  32. 

Virulence  of  strain,  variatioi.  of,  49. 

Vomiting,  with  acute  febrile  erythema, 
1 14  ;  with  the  toxaemia,  60  ;  with 
toxic  smallpox,  100. 

Washboume  on  the  pathology  of 
smallpox,  8. 


Pbinted  by  Casseix  Ac  Company,  LiMiTHn,  La  Belle  Sauvage,  London,  E.C. 


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IN  U.  S.  A. 

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A  000  421816 


WC585 
R539d 
1910 
Ricketts,  Thomas  F 

The  diagnosis  of  smallpox 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92661 


